Is there such a thing as s/l Preda insulin? <- under heading of current medications
Posted By: ne on 2007-09-30
In Reply to:
Subject: Is there such a thing as s/l Preda insulin? <- under heading of current medications
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under current medications
Subject: under current medications
S/L: HYDRO-CO-LOR-OX 25 mg
hydrochlorics ??
Current medications: s/l *en-do-said* 7.5/500 one b.i.d. p.r.n. tia/nm
Subject: Current medications: s/l *en-do-said* 7.5/500 one b.i.d. p.r.n. tia/nm
it includes in his current medications
Subject: it includes in his current medications
amlodipine, Budeprion, __(nephro-lite/-light)___, lorazepam, hydrocodone, alprazolam, and RenaGel.
The patient was given 5 medications by the s/l CD to take. Current Dr maybe??
Subject: The patient was given 5 medications by the s/l CD to take. Current Dr maybe??
The medication isn't for the bone infection, it is in his current medications list, but thanks.
Subject: The medication isn't for the bone infection, it is in his current medications list, but thanks.
Past medical history: Arthritis, diabetes, gout, MI, heart murmur, hypertension, hyperlipidemia.
Current Medications: Glucophage, _____, glyburide, gemfibrozil, ferrous sulfate, Zocor, allopurinol, aspirin, Adalat, Toprol XL, furosemide, Avandia, Prinivil.
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
insulin requiring and NPH insulin
Subject: insulin requiring and NPH insulin
T current and T max?
Subject: T current and T max?
Can someone tell me the correct way to transcribe "T current and T max"? Thanks a bunch!
I was told by my QA T-current and T-max,
Subject: I was told by my QA T-current and T-max,
but someone else may have a different opinion. If the account I am doing is not verbatim then I transcribe current temperature and maximum temperature because I consider those terms to be slang. Again, others may have different opinions but I haven't had any complaints.
URBY current?
Subject: URBY current?
In a standard pull-type fashion, an 8-mm biliary sphincterotomy was performed using s/l Urbee/Erbee current, without any complications.
current not an issue?
Subject: current not an issue?
That is my current guess.
Subject: That is my current guess.
About to turn it in blank.
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?
States current medication..
Subject: States current medication..
she is being seen for left arm numbness. Does that help any? Nothing in history.
The current trend seems to be to do away with hyphens when possible
Subject: The current trend seems to be to do away with hyphens when possible
That doesn't make it correct, but that's what I've been told to do on several accounts, including the last time I worked in-house.
current medication s/l mobaz nm tia
Subject: current medication s/l mobaz nm tia
thanks for the pick me up. I just had to quit my current job...sm
Subject: thanks for the pick me up. I just had to quit my current job...sm
because my family was getting fed up with my long hours ( and myself)and I had a very,very good dictator. I hated to do it but I was under the impression that there were companies out there where p/t was 500-600 lines a day. THat is the amount of work that I can handle right now.
On my current account we cannot use slang and
Subject: On my current account we cannot use slang and
were told to use saturating.
I believe that current preference these days is
Subject: I believe that current preference these days is
followup, without the dash. Back in the old days it was follow-up or follow up. I would go with whatever the client wants, I have one that wants the dash, one that does not.
NM found it! direct current
Subject: NM found it! direct current
I guess I have gotten used to coming here I thought I'd ask instead of searching the internet first like i used to... sorry guys found it, thanks anyway :)
(direct-current) DC cardioversion
Subject: (direct-current) DC cardioversion
His current Rx includes (s/l Narnia) 700 mg q. day - nm
Subject: His current Rx includes (s/l Narnia) 700 mg q. day - nm
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?
AAMT BOS current edition prefers x2 (pg 428). nm
Subject: AAMT BOS current edition prefers x2 (pg 428). nm
xx
hepatic? biliary? Does it seem like it pertains to current
Subject: hepatic? biliary? Does it seem like it pertains to current
s
s/l "positive of current atelectasis" - I am trying to hear him
Subject: s/l "positive of current atelectasis" - I am trying to hear him
thanks for all help - they were diagonal 1 and direct current cardioversion
Subject: thanks for all help - they were diagonal 1 and direct current cardioversion
current correct cancer staging
Subject: current correct cancer staging
Have not done oncology for a couple years.
Stage T1-C andenocarcinoma, Gleason 6 ???
Thanks!
Listed in current meds s/l PAIRosh? Any help?
Subject: Listed in current meds s/l PAIRosh? Any help?
Sorry, this should have been under heading Physical Examination.
Subject: Sorry, this should have been under heading Physical Examination.
In my opinion, should be spelled out in heading
Subject: In my opinion, should be spelled out in heading
nm
Not the OP, but a skin prep would be under a different heading
Subject: Not the OP, but a skin prep would be under a different heading
s
Heading in exam? COR: Cardiac etc.
Subject: Heading in exam? COR: Cardiac etc.
Make INFORMANT a new heading.
Subject: Make INFORMANT a new heading.
CHIEF COMPLAINT:
Lump on the side of the neck.
INFORMANT:
Mother and patient.
i would say Examination and Evaluation needs to be put as a heading.
Subject: i would say Examination and Evaluation needs to be put as a heading.
just my thoughts.
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