Interstital tissue and pelves need headings?
Posted By: Amanda on 2009-02-17
In Reply to:
Subject: Interstital tissue and pelves need headings?
Spleen: The spleen has a thin fibrous capsule. Malpighian bodies are indistinct the sinusoids are moderately widened.
Liver: Sections of the liver show a thin fibrous capsule. Multiple small fatty vacuoles are noted in the cytoplasm. Portal spaces are fairly small in size. There is mild widening of the sinusoids in the central zones.
Kidneys: The kidneys have a thin capsule. The cortices that show glomeruli of normal appearance. The tubules are not remarkable.
Interstitial tissue showed no note worthy change. The pelves are not remarkable.
In this instance.. does the interstitial tissue and pelves need their own headings.. or is this correct?? Thanks
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Pelves is plural for pelvis.
Subject: Pelves is plural for pelvis.
Headings
Newbie here. If a doc dictates a laboratory data and lists lab values, then talks about x-rays and ekgs, do you include that in the lab section or make a separate heading for x-rays and ekgs (what would you title that section?). Thanks for any info.
Headings
Subject: Headings
I am transcribing a History & Physical Examination Report (Neurology)
The headings confuse me terribly. What would the heading be for the following:
Orientation and language are normal fundi with sharp disks bilaterally.
I have the following:
NEUROLOGIC: Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on tandem walk she really has difficulty with that. She does not line up her toes easily and loses her balance very easily with that. (Is that the correct heading?)
Also, does anyone have a good website for determining headings?
headings
Subject: headings
Thanks so much. Does it get better?
Headings
Subject: Headings
If in a report , broke into 2 sections.. MRI of the Right leg then left..
and said
History
Technique
then
Technique
History
would it be a good idea to switch order for consistancy?
not an answer on headings, but
Subject: not an answer on headings, but
Sorry, I don't have a quick answer about your headings, but I wanted to let you know that your first sentence should be 2 sentences: Orientation and language are normal. Fundi with sharp disks bilaterally. (Fundi and disks/discs refer to the eyes, nothing to do with orientation or language.) Good luck with the headings - I still get confused sometimes on them too if I don't have a specific format to follow.
If QA has no recommendations, you don't have to have headings in there at all. Just do the report
Subject: If QA has no recommendations, you don't have to have headings in there at all. Just do the report
s
verbatim, abreviations, and headings?
Subject: verbatim, abreviations, and headings?
typing verbatim. In headings PREOPERATIVE DIAGNOSIS and POSTOPERATIVE DIAGNOSIS, when doc says same for POSTOP. Do you type same when typing verbatim?
Progress Note headings?
Subject: Progress Note headings?
I really want to hear Chief Complaint, but I’m sure he starts with Cardio. Thanks anyway.
Progress Note headings?
Subject: Progress Note headings?
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Headings are allowed to be added.
Subject: Headings are allowed to be added.
It would look weird without a heading. Thanks.
History & Physical Headings
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
History & Physical Headings+1>?
Subject: History & Physical Headings+1>?
Thanks. One more question. What headings do you add if not transcribed to the H & P?
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
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.
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Subject: tissue
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It sounds like "g-by-lased" tissue. He is a mumbler Thanks!
tissue
Subject: tissue
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He definitely says tissue, though.
Subject: He definitely says tissue, though.
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Subject: Tissue checks?
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No idea on this one. Not even sure where to research.
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Subject: 'tissue glue'.........
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Subject: Tongue of tissue
Anyone ever heard of a "tongue" of intestinalized tissue. Pnt has Barret's and is having an EGD and twice I heard what sounds like "tongue" of tissue.
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I can't find it. Thanks.
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Subject: s/l perivasal tissue? sm
Doing a vasectomy.
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Subject: Maybe: fibrofatty tissue with
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Subject: Fibroconnective tissue? NM
X
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Subject: listened again and it is scar tissue
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Subject: Zo-Med soft tissue shaver (sp Zo-Med?) nm
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Subject: s/l soft tissue signal
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Subject: Could it be 'necrotic' muscle tissue (nm)
possibly...passage of tissue?
Subject: possibly...passage of tissue?
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Subject: Soft tissue balance??
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Subject: okay that's supposed to be TISSUE seen in the "oss" :) nm
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Subject: Soft tissue mass
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And no comma between tissue and manipulation. NM
Subject: And no comma between tissue and manipulation. NM
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Subject: tissue expansion is the only thing I can
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Subject: it IS tissue expander or expansion....
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Subject: the s/l media-appearing tissue
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