I was under the impression it was JCAH mandated to write ml instead of cc. NM
Posted By: Ditto here on 2007-11-01
In Reply to: I'm not allow to put either. We use mL. - MslaMT
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM
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Help with IMPRESSION
Subject: Help with IMPRESSION
Should this be dictated like this?
1. Hyponatremia, rule out subdural hematoma.
OR
1. Hyponatremia.
2. Rule out subdural hematoma.
impression
Subject: impression
type it with a semicolon in between.
Impression
Subject: Impression
Hi Shirl -
Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.
Some usual headings in a radiology report are:
CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.
FINDINGS: or RESULTS:
IMPRESSION: or OPINION:
Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression
In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression
Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm
IMPRESSION prob
Subject: IMPRESSION prob
I have a problem under impression  ...
"D: IMPRESSION: Occipital neuralgia probable acute gastroenteritis"
question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?
NOTE: but the dictator did not dictate any numbering.... 
Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not? TIA!
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or
the a new section after it.
Thanks :)
Impression - hypertension
Subject: Impression - hypertension
This is under impression on a history and physical examination.
It is a numbered list.
[Sodiunduradine] is hypertension.
Any suggestions would be great!
It was under the impression section
Subject: It was under the impression section
I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.
Pt with mental retardation.
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.
it's impression and lung markings....
Subject: it's impression and lung markings....
No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.
impression, SP - status post
Subject: impression, SP - status post
nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression
Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression. Help appreciated.
Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm
Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
ss
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.
Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm
impression: bronchiolitis s/l sublets? or other process
Subject: impression: bronchiolitis s/l sublets? or other process
s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan
Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon
Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"
Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM
(s/l shrowd ligament rupture).
nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Subject: nevermind it's 'off' axis. He repeated it in the impression much more clearly!
I was under the impression that VAC is an acronym for vacuum-assisted closure.
Subject: I was under the impression that VAC is an acronym for vacuum-assisted closure.
Both Stedmans acronyms and Tessier surgical have it as VAC.
saw the patient, and the impression was s/l brass sediment impaction?(
Subject: saw the patient, and the impression was s/l brass sediment impaction?(
Firstly, would it be Impression: (instead of "colon") Negative mammography...
Subject: Firstly, would it be Impression: (instead of "colon") Negative mammography...
The dictation after just went straight into the impression, so I didn't include it. nm
Subject: The dictation after just went straight into the impression, so I didn't include it. nm
nm
So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Subject: So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Lumbar spine MRI. He says: Impression - ?quiet? degenerative changes.
Subject: Lumbar spine MRI. He says: Impression - ?quiet? degenerative changes.
Cardio. Dictates ostium to TM in Impression. Can't find expansion...
Subject: Cardio. Dictates ostium to TM in Impression. Can't find expansion...
that makes sense in any references and nothing in rest of dictation that connects. Got any ideas?
Gracias!
Thank you, I will also write this down.
Subject: Thank you, I will also write this down.
x
How do you write this....
Subject: How do you write this....
When the dictator says, "enclosure and copy cc to"...
Thanks!
how to write this.....
Subject: how to write this.....
one more question for today.........
How do I correctly write the 1-to-100,000 in this sentence?.........
2% Xylocaine with 1-to-100,000 epinephrine was injected subcutaneously
how to write something please....
Subject: how to write something please....
MRA: Abdominal aorta. No evidence for renal artery stenosis. OR
MRA abdominal aorta. No evidence for renal artery stenosis.
The doctor started out with the ECG findings then went to this. Or would this go under the ECG heading? Thanks
How to write it:
Subject: How to write it:
1:1,000 as a ratio
How to write Q.o.d.
Subject: How to write Q.o.d.
q. o.d. or Q.o.d. or qod?
I cannot find that one in BOS.
Thanks!
How would you write this? sm
Subject: How would you write this? sm
"When he Valsalvas I can appreciate the hernia..." Would it be Valsalva's or valsalvas, or what? TIA
Not sure how to write this
Subject: Not sure how to write this
generally a one-on-one student-faculty rotation. Should I have the hyphens between all of these or just one on one? Not sure which would be correct. This is a letter of recommendation and need to be correct with it.
Thanks
Write it out per BOS II. nm
Subject: Write it out per BOS II. nm
s
Thank you. I will write that one down!! nm
Subject: Thank you. I will write that one down!! nm
Don't know how to write this...
Subject: Don't know how to write this...
Patient has had recent diagnosis of diabetes with recent hemoglobin A1c over 12.
Thanks in advance!
how to write JVP
Subject: how to write JVP
JVP is estimated at 8-10 cm of water at 90 degrees? Is this correct? I have never heard this type of description before.
how would you write this?
Subject: how would you write this?
The final diagnosis was a "grade 2 of 3" mixed glioma
Would you write "2 of 3" or would you write 2/3?
I wasn't sure...thanks!
How do you write....
Subject: How do you write....
an expression of solution such as if dictated like one to one thousand, would I write is like this 1:1000?
how do I write this?
Subject: how do I write this?
How do I write the "eight two fraction" part???
The patient does have a hypochromic microcytic anemia and her hemoglobin electrophoresis does show a reduced hemoglobin A with an increased "8, 2 fraction" and increased hemoglobin F, all compatible with her history of beta thalassemia
How to write this . . . SM
Subject: How to write this . . . SM
Platelets are elevated at "twelve sixty eight"
12.68 ?
PSA - do you write this out?
Subject: PSA - do you write this out?
I am working on a History and Physical Examination, he dictated after the History the following: PSA, on Nilandron 150 mg daily, has been elevated but stable with last PSA 4.8. Do I need tp type it like this? Prostate-specific antigen (PSA), on Nilandron 150 mg daily, has been elevated but stable with last PSA 4.8. Since this is the first mention of the PSA or is that LAB where it should be understood?
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