I would make dg meds a heading, then type Patient is still... under it. nm
Posted By: curious george on 2007-01-22
In Reply to: need to know the right way to transcribe.... - rf
Subject: I would make dg meds a heading, then type Patient is still... under it. nm
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Make INFORMANT a new heading.
Subject: Make INFORMANT a new heading.
CHIEF COMPLAINT:
Lump on the side of the neck.
INFORMANT:
Mother and patient.
Culture and sensitivity would be right like you have it. You don't need to make a heading for it
Subject: Culture and sensitivity would be right like you have it. You don't need to make a heading for it.
another one- for meds. Patient was in for....
Subject: another one- for meds. Patient was in for....
bowel obstruction, had exploratory laparotomy with adhesiolysis and enterotomy of small-bowel decompression. For meds-He also had difficulty with blood pressure control, but did obtain some reasonable semblance of control on clonidine 0.6 mg patches as well as some supplemental IV hydralazine. switched to IV Solu-Cortif since he had been on 5 mg of Prednisone orally for his spondylitis. He was initially started on s/l Clivicten on the 3rd postoperative day, but this had to be stopped. Reglan was added to his regimen. Cannot find what this drug would be. Sorry so long
Or - does patient take meds for depression, etc.?
Subject: Or - does patient take meds for depression, etc.?
Patient with type 2 diabetes prescribed a s/l glutisone type drug. nm
Subject: Patient with type 2 diabetes prescribed a s/l glutisone type drug. nm
patient was prescribed meds for gastroenteritis.nm
Subject: patient was prescribed meds for gastroenteritis.nm
xx
Could be, as in they had the patient make
Subject: Could be, as in they had the patient make
x
meds help! synthroid, s/l *4PL*, calcium plus D, for patient with osteporosis and osteoarthritis. nm
Subject: meds help! synthroid, s/l *4PL*, calcium plus D, for patient with osteporosis and osteoarthritis. nm
I am not sure what type of report you are doing, but could it be amantadine and Zetia for the 2 meds
Subject: I am not sure what type of report you are doing, but could it be amantadine and Zetia for the 2 meds ?
Ok I figured out the meds and just need help with the needle type 22 gauge s/l fee sometimes and cl
Subject: Ok I figured out the meds and just need help with the needle type 22 gauge s/l fee sometimes and clicking or criqui other times
Thanks for the help!
Patient with AIDS, doctor spells two meds, Travata and Cysteva. sm
Subject: Patient with AIDS, doctor spells two meds, Travata and Cysteva. sm
I can't document either. Any help appreciated! TIA
I would type it how she says it, but make it
Subject: I would type it how she says it, but make it
xx
Does this make sense? 'The patient has had a
Subject: Does this make sense? 'The patient has had a
The patient has had a 'preformal' history of left shoulder pain.
how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
If he says grade 2 out of 3, the only change I would make is to use numbers and not type out the wo
Subject: If he says grade 2 out of 3, the only change I would make is to use numbers and not type out the word "two". The rest is fine.
Would it make sense to type x-ray is pending over read? TIA
Subject: Would it make sense to type x-ray is pending over read? TIA
LOL, perhaps the patient feels very "negative" about females? These docs can make you smile,
Subject: LOL, perhaps the patient feels very "negative" about females? These docs can make you smile, huh? nm
nm
Patient is oriented to time, person and place with good *respondent* memory. Does this make sense?
Subject: Patient is oriented to time, person and place with good *respondent* memory. Does this make sense?
should I type patient's with apostrophe? Thanks
Subject: should I type patient's with apostrophe? Thanks
I did communicate with the patient through a friend of the patient’s whose English was marginal
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...
Type and hold. Patient may need transfusion?
Subject: Type and hold. Patient may need transfusion?
x
Could you type the sentence out completely? Also what is the patient being seen for?
Subject: Could you type the sentence out completely? Also what is the patient being seen for?
Patient has a persistent s/l pil-rong type tic.
Subject: Patient has a persistent s/l pil-rong type tic.
nm
what is the correct way to type patient was *medevaced*??? Thanks. nm
Subject: what is the correct way to type patient was *medevaced*??? Thanks. nm
nm
s/l Chanz-type injury. The patient has a fracture...sm
Subject: s/l Chanz-type injury. The patient has a fracture...sm
subluxation of the thoracic spine.
ortho help. The patient had a s/l jersey-type injury with SM
Subject: ortho help. The patient had a s/l jersey-type injury with SM
disruption of the profundus tendon of her left ring finger. TIA
Does this patient have cancer? If so, do they state what type? Almost sounds like a new drug
Subject: Does this patient have cancer? If so, do they state what type? Almost sounds like a new drug
therapy? It would help to know the diagnosis. Does the doc state what the diagnosis is?
s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
Subject: s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
States: "Review of report in ____ suggests..." Again later in dictation: "Although this is not charted in ____. "
no speciality. final diagnosis was uti. these meds were admit meds, only hist was hypertension
Subject: no speciality. final diagnosis was uti. these meds were admit meds, only hist was hypertension
Forgot to add, would "Veress-type" make sense? S/l pronounced "Veress'," possessive.
Subject: Forgot to add, would "Veress-type" make sense? S/l pronounced "Veress'," possessive... nm
nm
Patient with pruritic rash. No known exposures to s/l dosica dendron type plants.
Subject: Patient with pruritic rash. No known exposures to s/l dosica dendron type plants.
The only thing I can find close is subtilise meaning to make senses more keen or make one's sense
Subject: The only thing I can find close is subtilise meaning to make senses more keen or make one's senses more acute?
I'm still listening and trying to fit it together to make any suggestions make sense.
Subject: I'm still listening and trying to fit it together to make any suggestions make sense.
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
Thanks.
Under what heading would you SM
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
TIA
EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
EKG: EKG today show no ST wave changes.
Heading?
Subject: Heading?
This is for a psych. consult. After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.
I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records. Past Medical History, yes, but not the other. Any ideas?
Oops, used same heading, need help
Subject: Oops, used same heading, need help
Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".
Thanks
IV abbreviated in heading
Subject: IV abbreviated in heading
Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?
under abdomen heading
Subject: under abdomen heading
s/l "the PICC was created" or "the tic was created"
Angie
Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?
I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with
s
I think doc left heading out sm
Subject: I think doc left heading out sm
He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.
What would be asymmetrical here?
I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm
One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
A lot of facilities use the heading
Subject: A lot of facilities use the heading
"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?
Just wondering under what physical exam heading other MTs put this finding under.
TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.
I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they
want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?
I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
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