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Impression - hypertension

Posted By: Krystal on 2009-02-10
In Reply to:

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!




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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!
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Subject: Impression

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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


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Subject: IMPRESSION prob

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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 :)
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Subject: It was under the impression section

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On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.

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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.


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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
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Subject: GI help: Is it diaphragmatic compression or impression

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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.


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Subject: Could you post the impression? Might help to shed light. nm


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Subject: impression: bronchiolitis s/l sublets? or other process


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Subject: The dictation after just went straight into the impression, so I didn't include it. nm

nm
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 that makes sense in any references and nothing in rest of dictation that connects.  Got any ideas?


Gracias!


hypertension

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Subject: Hypertension, currently not NSU or IN SU?

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Subject: He does have hypertension..

Maybe that is it, I will have to go listen again.  There is no dictated dosage.  Thank you so much for your help!
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Subject: Are you sure he isn't saying pulmonary hypertension

?
There is Avalide for hypertension? sm
Subject: There is Avalide for hypertension? sm

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x
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