If not dictated separate, then combine.
Posted By: NM on 2009-02-10
In Reply to: ASSESMENT/PLAN COMBINED? - A
Subject: If not dictated separate, then combine.
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You can combine any medical term with
Subject: You can combine any medical term with
another as long as it makes sense, which this does.
Then they combine them into EAR, EPOCH, and a kazillion other regimens. nm
Subject: Then they combine them into EAR, EPOCH, and a kazillion other regimens. nm
nm
I would combine it and give the doc what they're saying. Combining forms is done often enough. nm
Subject: I would combine it and give the doc what they're saying. Combining forms is done often enough. nm
s
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
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.
They are separate. sm
Subject: They are separate. sm
The common bile duct is the duct formed by the union of the cystic duct (from the gallbladder) and the hepatic duct, which is formed by the intrahepatic biliary tree.
Separate them. nm
Subject: Separate them. nm
s
It should be separate, SAD/DCR or SAD-DCR, or SAD, DCR
Subject: It should be separate, SAD/DCR or SAD-DCR, or SAD, DCR
Shoulder arthroscopic debridement and distal clavicle resection. Gotta love these docs and their neverending shortcuts, just lazy behinds. LOL
No they do not go together. Separate
Subject: No they do not go together. Separate
x
I personally would just separate
Subject: I personally would just separate
by a slash 500/500/250/500, but that's just me :)
Could he mean separate consult?
Subject: Could he mean separate consult?
Ugh..can you separate your s/l into syllables for us, please? Thx. nm
Subject: Ugh..can you separate your s/l into syllables for us, please? Thx. nm
s
Well, BOS pg 12 says use a comma to separate 2 or
Subject: Well, BOS pg 12 says use a comma to separate 2 or
v
Can you separate your s/l into syllables for us? nm
Subject: Can you separate your s/l into syllables for us? nm
s
Yes, 2 separate items. nm
Subject: Yes, 2 separate items. nm
s
No they are three separate views.
Subject: No they are three separate views.
No they are 3 separate views.
It is the sentence structure that is confusing. Three individual views, but once the word views gets put into the sentence it becomes plural and without the word views it is regarded as singular. I don't necessarily agree, but I believe this is why the QA department and your manager keep changing your grammar.
I believe tumor is separate...
Subject: I believe tumor is separate...
"s/l H nerve, tumor, or other..."
I keep them separate, i.e. mid portion.
Subject: I keep them separate, i.e. mid portion.
x
Seems like that goes with Nystatin and not a separate drug -
Subject: Seems like that goes with Nystatin and not a separate drug -
x
it is prothrombin time, to separate....sm
Subject: it is prothrombin time, to separate....sm
When it is really prothrombin time, it makes NO sense to type pro time as 2 words....I really don't care what BOS says about this one particular issue. The word really is prothrombin time and MDs say protime....I give them protime. Just my take on it.
Sorry. Put answer on separate entry. nm
Subject: Sorry. Put answer on separate entry. nm
Could your s/l be something separate from "cardiac disease," sm
Subject: Could your s/l be something separate from "cardiac disease," sm
such as whatever it is, cardiac disease, and congestive heart failure. Any clues in the rest of report?
This has got me stumped.
I believe the are 2 separate diagnoses and would transcribe as such.
Subject: I believe the are 2 separate diagnoses and would transcribe as such.
.
Are you hearing this with an accent? Can you separate it into
Subject: Are you hearing this with an accent? Can you separate it into
s
Also, with the periods it would be 3 separate words, which it is not...
Subject: Also, with the periods it would be 3 separate words, which it is not...
cerebrovascular accident always has been CVA (hard to keep up with so many new rules).
can only find two separate angles. sm
Subject: can only find two separate angles. sm
metatarsus adductus angle, and intermetatarsal angle. You probably already knew that, and it probably doesn't help decipher what your doc really means.
2 separate vital signs nm
Subject: 2 separate vital signs nm
nm
I agree, 3 separate things. nm
Subject: I agree, 3 separate things. nm
.
Depends on what your QA says, but I separate out the entities and only use headings if
Subject: Depends on what your QA says, but I separate out the entities and only use headings if
s
Just means 2 separate entities. It would fit. Or maybe it's "continued?" nm
Subject: Just means 2 separate entities. It would fit. Or maybe it's "continued?" nm
s
maybe "sent separately" - as in a separate specimen
Subject: maybe "sent separately" - as in a separate specimen
The doc says, through a separate subfascial skin incision when...sm
Subject: The doc says, through a separate subfascial skin incision when...sm
harvesting iliac crest during a spinal fusion. It doesn't make sense to me. I would think it would need to be either a separate subfascial incision or a separate skin incision. I have never heard it described this way before and I don't think it makes sense his way.
I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
Subject: I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
nm
I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
Subject: I have always used and seen S1, S2, two separate heart sounds during auscultation......nm
nm
antinuclear antibody is separate test from CBC...sm
Subject: antinuclear antibody is separate test from CBC...sm
may be saying antinuclear antibody assay and CBC?
Pretty sure they're two separate problems. nm
Subject: Pretty sure they're two separate problems. nm
Thanks so much! I knew of the two separate, but questioning myself on something I didn't know.
Subject: Thanks so much! I knew of the two separate, but questioning myself on something I didn't know. Thx
They're all likely related, but I'd personally do 3 separate dxs. n/m
Subject: They're all likely related, but I'd personally do 3 separate dxs. n/m
In the sentence you describe, I would not separate by common and use v or vs instead, as cited by...
Subject: In the sentence you describe, I would not separate by common and use v or vs instead, as cited by...
Cambridge Dictionary:
(WRITTEN ABBREVIATION v or vs) used to compare two things or ideas, especially when you have to choose between them:
i.e., private education versus state education
Yes, but if lab stuff, try and separate the "components" if you're sure of them with semico
Subject: Yes, but if lab stuff, try and separate the "components" if you're sure of them with semicolons or
s
This is grip strength bilaterally. The others were on separate hands.
Subject: This is grip strength bilaterally. The others were on separate hands.
when the doc does this, I usuall separate with a forward slash if there are no other diagnoses...nm
Subject: when the doc does this, I usuall separate with a forward slash if there are no other diagnoses...nm
x
Wild guess here...Could the dictator be referring to two separate medications, i.e. "she had been
Subject: Wild guess here...Could the dictator be referring to two separate medications, i.e. "she had been given a refill for her birth control pills and Cefprozil (antibiotic?).
Trying to find possible AIDS drug. S/l eltripla protease inhibitor. May be two separate drugs. (?)
Subject: Trying to find possible AIDS drug. S/l eltripla protease inhibitor. May be two separate drugs. (?)
nm
They are 3 separate things, sponge, lap and needle counts. Laps are not only sponges but also pads.
Subject: They are 3 separate things, sponge, lap and needle counts. Laps are not only sponges but also pads.
My Stedman's spell check comes back with pro embolic (2 separate words). Pro is a word in itself
Subject: My Stedman's spell check comes back with pro embolic (2 separate words). Pro is a word in itself as is embolic. Hope this helps.
for PA- DICTATED BY PA's name...nm
Subject: for PA- DICTATED BY PA's name...nm
x
Dictated 427 rbc's and 58 rbc's
Subject: Dictated 427 rbc's and 58 rbc's
what was dictated; if not, do it your way...NM
Subject: what was dictated; if not, do it your way...NM
x
what was actually dictated?
Subject: what was actually dictated?
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