Is it in the operative diagnosis or in the body of the report?
Posted By: Colleen on 2008-05-04
In Reply to: Missed AB or abortion? - Michelle
Subject: Is it in the operative diagnosis or in the body of the report?
Is the account verbatim? Abbreviations are not acceptable (most places) if they are used in the diagnosis headings, but are okay if in the body of the report, unless the facility has requested otherwise.
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If it is used in heading, as in Diagnosis: XXX, then yes, but if just in body of report in sentence,
Subject: If it is used in heading, as in Diagnosis: XXX, then yes, but if just in body of report in sentence, ...sm
you can abbreviate, depending on acount specifics and what your company or doctor wishes. Hope this helps!
An operative report...SM
Subject: An operative report...SM
We have three options for the nasal fill area. We discussed allowing this to heal by secondary intention, full-thickness skin graft, and _____ tissue transfer.
Operative report
Subject: Operative report
She required a microround, a minute of Dopamine to maintain her pressure.
I'm not sure if microround is what he is saying. Do they use that term? Thank you.
Operative report
Subject: Operative report
I am having a really hard time understanding this doctor. I've researched this term (or what I think he's saying) without any luck. I always turn to you guys last and you always seem to come up with the answer. Thanks for the help! At the end of the report he dictates anesthesia, IV fluids etc. Then he says something that sounds like this " Line: LB and RT line or Line: Albi and ulti line. "
operative report
Subject: operative report
is there a palmary bilateral tubal ligation?
operative report help please
Subject: operative report help please
patient undergoing c section and tubal ligation . . . s/l malar incision - I found malare, is this correct?
operative report
Subject: operative report
diagnosis is carcinoma of the lymph, when the doctor is given the name of the operation I can't make it out---S/L X-WORSE PROCEDURE any idea'a? thanks for you help!!
Operative Report help
Subject: Operative Report help
How do I correctly type this:
Then, tumescent fluid 250 mL to the right and left upper abdomen areas, each was placed using (says 1 and 1 million) Epinephrine into the subcutaneous tissues, attention was then turned to each flank where 500 mL was placed into each flank area.
Would it be 1:1000000
Thanks in advance.
HELP WITH CATARACT OPERATIVE REPORT
Subject: HELP WITH CATARACT OPERATIVE REPORT
Hi, everyone, need help right quick ---
Doctor dictates in a heading:
ANESTHESIA: TOPICAL AND _____ WITH IV SEDATION.
He says intracameral --- but I cannot verify anywhere. Does he mean intracanalicular?
Thanks....
Dental operative report
Subject: Dental operative report
sentence: Direct nasal endotracheal intubation was established with a size 5.5. nasal __________ tube.
Sounds like nasal 'ray' tube. Is 'ray' correct?
s/l Avoseal used in an operative report for TAH? nm
Subject: s/l Avoseal used in an operative report for TAH? nm
x
missed abortion d&c sample operative report
Subject: missed abortion d&c sample operative report
missed abortion d&c sample operative report
operative report...placed on a flur-au-three table. nm (new doctor).
Subject: operative report...placed on a flur-au-three table. nm (new doctor).
thanks.
What part of the body, diagnosis or in reference to ?
Subject: What part of the body, diagnosis or in reference to ?
Got a body part? Report type? Something before and after this???nm
Subject: Got a body part? Report type? Something before and after this???nm
s
Hate those things. I put them after the body of the report. sm
Subject: Hate those things. I put them after the body of the report. sm
but before the signature. Makes it easier. We typed our reports on sticky paper and that way it did not get separated from the main report etc. But I did not do BOS. nm
Got a name of a body part or system? Is this a history or an op report? nm
Subject: Got a name of a body part or system? Is this a history or an op report? nm
s
In what kind of report? Body part mentioned? The sentence? nm
Subject: In what kind of report? Body part mentioned? The sentence? nm
s
what part of the body does the report reference. More info. is helpful, as
Subject: what part of the body does the report reference. More info. is helpful, as
x
should dept. (neurology, neurosurgery) be capped in the body of a report?
Subject: should dept. (neurology, neurosurgery) be capped in the body of a report?
TIA
or just operative indications
Subject: or just operative indications
.
Thanks everyone. I don't do those kinds of operative note often enough.
Subject: Thanks everyone. I don't do those kinds of operative note often enough.
nm
Operative prep s/l coaxane?
Subject: Operative prep s/l coaxane?
Dictator states he prepared the patient's right groin with s/l coaxane or glaxane? Thank you.
Orthopedics operative note help please ...
Subject: Orthopedics operative note help please ...
"He was found to have a complete rupture. He was s/l *diastased* about 1.5 cm or so and he had some early scar tissue forming. Debrided all of this down until we got to decent looking, healthy Achilles tissue."
TIA
I've heard "limited due to body habitus" or "difficult due to body habitus." Not sur
Subject: I've heard "limited due to body habitus" or "difficult due to body habitus." Not sure.
x
Findings in operative: Uterus s/l "tone seismic" position
Subject: Findings in operative: Uterus s/l "tone seismic" position
Uterus s/l "tone seismic" position. Cervical os about already dilated. Uterus was sound to 10 cm. Moderate amount of s/l horrific flexion" were obtained. No adnexal mass is palpable.
Operative note on finger~phyte phyte infection?
Subject: Operative note on finger~phyte phyte infection?
agghh! i can't find it and he says it 3 times! none any clearer than the first time around Thanks!
Where in the body is it being used? nm
Subject: Where in the body is it being used? nm
s
where are you in the body?
Subject: where are you in the body?
Is it the same part of the body or different
Subject: Is it the same part of the body or different
subchondral sclerosis can happen in many different joints of the body...
what part of the body is the x-ray of? nm
Subject: what part of the body is the x-ray of? nm
:
What part of the body are we in? nm
Subject: What part of the body are we in? nm
What part of the body?
Subject: What part of the body?
x
half the body --
Subject: half the body --
I'm thinking it's hemibody.
what body part?
Subject: what body part?
what part of body?
Subject: what part of body?
x
What part of body?
Subject: What part of body?
Of what part of body? nm
Subject: Of what part of body? nm
s
What part of body is this on?
Subject: What part of body is this on?
If it's a foot, can you hear hallux valgus? I'm wondering if the "salbeck" you are hearing is supposed to be a type of bunionectomy, but we are at a terrible disadvantage if we don't know if this is bunion surgery.
What part of the body are you in?
Subject: What part of the body are you in?
Body temperature
Subject: Body temperature
Dictator states the patient's temperature is 75.7. (Patient is having a surgical consult for abdominal pain). This is the third time in as many weeks I've had physician dictate a body temperature in the 70s. Celsius temp is normally in the 30s, Farenheit - of course - is normally in the high 90s. Am I missing something here? Is there some other temperature scale I don't know about? So far I've flagged them as blanks.
Thanks!
what body part it is on? nm
Subject: what body part it is on? nm
.
What region of the body? He is
Subject: What region of the body? He is
probably referring to a lesion of the "pole" of a certain organ.
Where in the body is he working? nm
Subject: Where in the body is he working? nm
.
body habitus?
Subject: body habitus?
Used for which part of the body?
Subject: Used for which part of the body?
What part of the body are they using this for?
Subject: What part of the body are they using this for?
Not sure where you are in the body but there is a dermatocele?
Subject: Not sure where you are in the body but there is a dermatocele?
What part of body?
Subject: What part of body?
What is the sentence or where are you i the body?
Subject: What is the sentence or where are you i the body?
For which part of the body?
Subject: For which part of the body?
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