I personally always type as dictated, unless told otherwise. nm
Posted By: tt on 2009-06-05
In Reply to: Chart Note - Mary
Subject: I personally always type as dictated, unless told otherwise. nm
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- Chart Note - Mary
- I personally always type as dictated, unless told otherwise. nm - tt
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Personally, I type it as 10.4.
Subject: Personally, I type it as 10.4.
If I type C-spine, I personally use a capital
Subject: If I type C-spine, I personally use a capital
I personally type out the word discontinued. nm
Subject: I personally type out the word discontinued. nm
We type it as dictated, if dictated
Subject: We type it as dictated, if dictated
c spine we transcribe C-spine, if cervical then cervical spine.
I have been told to type the dates out
Subject: I have been told to type the dates out
but I think each hospital/client has a preference. I am going to be doing a different account where I work and now they want the dates as 6/30/2006. Go figure. They are trying to make us all crazy.
Are you working on your own or for a company? I would find out what the preference is if it is a company.
I type one-teens because that's how I was told to do it. nm
Subject: I type one-teens because that's how I was told to do it. nm
Agree with you on that one. I have type V.A.C. and I was told VAC.
Subject: Agree with you on that one. I have type V.A.C. and I was told VAC.
I find V.A.C. in Vera Pyle Medical Terminology and VAC in Surgical Word Book. If you ask me, they both are correct, but we need to go by what our particular accounts tell us. I believe we all work for different companies, hence different client profiles.
patient was told to F-off. How would you type that?
Subject: patient was told to F-off. How would you type that?
Would that be "F" off/ "F-off" ... Thanks alot...
We have been told not to type "include"
Subject: We have been told not to type "include"
when dictated like that, but as poster below said, it is all client preference.
Yes, purulent is how we were told to type it at one of my jobs
Subject: Yes, purulent is how we were told to type it at one of my jobs
xx
I was told at one time to type it as 110s
Subject: I was told at one time to type it as 110s
I would type it under PLAN and type what is dictated.
Subject: I would type it under PLAN and type what is dictated.
I have had that happen to me before, and I was told by QA to not move things around in the report, maybe that is the same for you, but if I were typing this report, I would type it in the order as is dictated, even if that means typing it under the heading PLAN. Also, his vitals were probably taken at the end of the exam as they were repeated, so it would make sense to type them again under that heading. Hope that helps!
I always type it the way you have it if that's the way it's dictated. sm
Subject: I always type it the way you have it if that's the way it's dictated. sm
Of course, go by your account specifics. If you can change it, some do. I always just type what they say and it keeps me out of trouble. :)
I would just type as dictated. nm
Subject: I would just type as dictated. nm
i would type as dictated.
Subject: i would type as dictated.
x
Type whatever he dictated.
Subject: Type whatever he dictated.
x
I'm with you, I type what is dictated. sm
Subject: I'm with you, I type what is dictated. sm
It is not my place to decide what the doctor means. I am not in any way offended by what he/she dictates.
You are correct, pus-like is not the same as pussy.
If they say the F word, I type the word, not asterisks in place of letters, because it's a direct quote from the patient. I do not change direct quotes.
Anybody who is offended by typing a word is putting way too much of their personal life into their work.
No, you type it as dictated.
Subject: No, you type it as dictated.
I type it as dictated.
Subject: I type it as dictated.
x
Just type it as dictated as it can mean more
Subject: Just type it as dictated as it can mean more
x
that is correct; type as dictated.
Subject: that is correct; type as dictated.
x
Same meaning - I would type as dictated
Subject: Same meaning - I would type as dictated
nm
If it is dictated clearly, I would type mid otitis.
Subject: If it is dictated clearly, I would type mid otitis.
Another way to say otitis media, albeit an uncommon one.
If dictated as C3/4/5 I would type it like that. Found you some examples. sm
Subject: If dictated as C3/4/5 I would type it like that. Found you some examples. sm
PDF] NON-OPERATIVE INTERVENTIONS
File Format: PDF/Adobe Acrobat - View as HTML
Cervical or Thoracic -- Transforaminal (Selective Nerve Root Block / Selective Epidural) ... bilateral, single level [C3-4 joint] [T4-5 joint] ...
www.theassr.org/pdf/codes_interventions.pdf - Similar pages |
[PDF] Techniques of epidural cannulation
File Format: PDF/Adobe Acrobat
epidural block is determined by the concentration and type of local ... the phrenic nerve outflow is blocked (C3/4/5) by local anaesthetic drugs, ...
www.extenza-eps.com/MPC/ doi/abs/10.1383/anes.5.5.152.34000 - Similar pages |
Cervical spondylotic myelopathy in elderly people: a high ...
CONCLUSIONS: A high incidence (95%) of focal conduction block at C3-4 or C4-5 with normal conduction at C5-6 and C6-7 characterises cervical spondylotic ...
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=PubMed&list_uids=10201416&dopt=Abstract - Similar pages |
[PDF] I nterventional Neuroradioliogy
File Format: PDF/Adobe Acrobat - View as HTML
vieHSvertebroplasty atT8 with epidural cement. F19.3, 4. Workstation reconstruction 01 the 3D CT ... mass nerve block is illustrated, and a C3/4 facet ...
www.visions-journal.com/GB-2003-V04/ S-16-20.pdf?PHPSESSID=12cfdacbc7ed1637eae12f702b51b6ed - Similar pages |
If you are on a verbatim account, type exactly what is dictated.
Subject: If you are on a verbatim account, type exactly what is dictated.
If you sense a discrepancy, you can flag it for your QA department.
I am on a verbatim account so I have to type it either way it is dictated L4-L5 or L4-5. As far OB/G
Subject: I am on a verbatim account so I have to type it either way it is dictated L4-L5 or L4-5. As far OB/GYN, G2, P3 or gravida 2, para 3 means with the 3-0-0-2: 3 live births, 0 preterm births, 0 miscarriages, 2 living children
Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
Subject: Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
it would be 1/4 pill or one fourth of a pill.
Def an 'N' dictated - Diabetes unsure of - no PMH dictated
Subject: Def an 'N' dictated - Diabetes unsure of - no PMH dictated
Personally, I don't see that being the
Subject: Personally, I don't see that being the
word, and if it was the word, I would think it would be fistula, not fisular. Since it came back from QA that way, I guess it has to fly, but personally...nah! Sorry. But to me, fisula is not even a word.
Personally, I would--sm
Subject: Personally, I would--sm
take out the comma between nucleations and right; I would also take out the comma between right and x 3, I would place a comma between fifth and "and". This is really a confusing sentence, as I am not sure if it means "right times 3" or right third, second, and fifth DIP joints. that would make a difference in the punctuation.
Personally, I would use the --sm
Subject: Personally, I would use the --sm
heading of CHIEF COMPLAINT: New patient with arm pain. or new patient, arm pain.
JMO
I personally
Subject: I personally
would do 1/1,000,000
Personally 3+3
Subject: Personally 3+3
I don't have anything personally against them (sm)
Subject: I don't have anything personally against them (sm)
But you're right...I have a lot of CNPs and PA-Cs who are constantly saying the wrong things. For example, the CNP who keeps saying dilution instead of deciliter for the UA, when she does an eye exam she always says the lids were averted instead of everted. She SPELLS it for me and always sounds like she's disgusted because she keeps spelling it with an A and I keep typing it with an E. It has always been Everted. Averted means to look away. I type these things up for years and years and then someone comes along like her and I start questioning myself, and maybe I'm typing it wrong...it just drives me crazy.
It could go either way, personally most
Subject: It could go either way, personally most
of the time I have heard things similar to this, the distally would go with the sensation.
Personally -
Subject: Personally -
I change it to match the context of the sentence - another x-ray, x-rayed again, etc.
If it is verbatim I would type re-x-ray.
I, personally..
Subject: I, personally..
would type it 4 x 4s-no apostrophe. :-)
I personally would just separate
Subject: I personally would just separate
by a slash 500/500/250/500, but that's just me :)
Grammar help! Myself personally
Subject: Grammar help! Myself personally
Dr. states. "I myself personally use drug-X."
or is it myself, personally?
Or leave out one or the other?
This is a verbatim account.
TIA!! 
Personally, I would leave out the myself--sm
Subject: Personally, I would leave out the myself--sm
that would be like saying "I me personally use the drug." verbatim or not, it is not good grammar, but it is your call. JMO.
Personally, I'd change it to, I was able to
Subject: Personally, I'd change it to, I was able to
get in touch with the patient's daughter, as I am my own QA. My doc lets me spritz up his letters all the time.
I personally capitalize it.
Subject: I personally capitalize it.
Hi there! I personally would not hesitate
Subject: Hi there! I personally would not hesitate
to type cruciates, just as he dictated it. JMHO.
It can be spelled either way. Personally, I use
Subject: It can be spelled either way. Personally, I use
CT scan. Just be sure whichever you choose, you are consistent with the spelling.
Personally I would use DeLee, they say it all
Subject: Personally I would use DeLee, they say it all
x
as in he personally has history of.... NM
Subject: as in he personally has history of.... NM
It is however your client wants. Personally,
Subject: It is however your client wants. Personally,
our client does not use slang, so we expand.
I personally always use "disk", but sometimes
Subject: I personally always use "disk", but sometimes
you have to go with the client's preference. Stedman's has it both ways. I have always asked what they prefer before starting an account - but that's me. 
Personally, I do not use the hyphen because
Subject: Personally, I do not use the hyphen because
"white matter" goes together as it is a part of the brain.
I personally don't use "q" anymore at all, but from
Subject: I personally don't use "q" anymore at all, but from
what I understand it's okay to use it in a non-medication context.
Personally I would capitalize since it is a brand name
Subject: Personally I would capitalize since it is a brand name
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