Just a general question on format
Posted By: Tracey on 2008-01-14
In Reply to:
Subject: Just a general question on format
I have been using these forums for a while now and I keep seeing people using "nm" and "sm". What does this mean?
nm = no message
sm = see message
Just a guess
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Here's a general ROS in general order : sm
Subject: Here's a general ROS in general order : sm
(they go from head to toe):
Constitutional, HEENT, Respiratory, (sometimes they give lymphatics before respiratory), Gastrointestinal, Genitourinary, Musculoskeletal (sometimes they say Neuromuscular),
Neurologic,
Endocrinologic, Hematologic,
Psychiatric,
Immunologic/Allergies.
What's missing in your review?
format
Subject: format
No.1 PDS or #1 PDS? Which is correct?
Format ?
Subject: Format ?
5/5 strength throughout sensation is intact. So the 5/5 is not at the start of the sentence, how would you reword this phrase?
OB format for G 3, P 1-1-0-2
Subject: OB format for G 3, P 1-1-0-2
Is this how you type that? I havn't heard it transcribed that way before... Thanks!
Format Help
Subject: Format Help
How do you type the name of a book? Italics or quotations? TIA
Format help
Subject: Format help
I have a dictator who constantly repeats words, phrases, entire sentences! Do you transcribe it twice or if she has already stated it, leave it out? 
Format ?
Subject: Format ?
Would it be MEDICATIONS: Include
1.
2.
3.
H & P Format
Subject: H & P Format
Just when I think I have it on format - I don't. The following is under PHYSICAL EXAMINATION. What would the subheading be?
Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on a tandem walk she really has difficulty with that. She does not line up her toes easily, loses her balance very easily with that. This is typed as dr. dictated. Suggestions would be appreciated.
Abbreviation Format
Hi... Can someone tell me the correct format for what comes after this med in a dictation: "Zarontin 250 mg 500 500 250 500?" Is this 500 am, 500 mid-am, 250 afternoon, 500 bedtime?
Thanks! 
Abbreviation Format
Subject: Abbreviation Format
Thanks! I thought that would be a mega-dose as well, but that's what she said. I did "slash" them though.
format question
Subject: format question
Do you put immunizations under the Social History section in a report or by themselves? I'm not testing, just confused. The doctor is dictating: "All immunizations are up to date" under Social History. Thanks.
Format question...
Subject: Format question...
Hi, I'm wondering whether AAMT BOS says to type this: "image #31 series 3" or this: "image #31, series 3." Comma or no?
Thank you! :D
Format question
Subject: Format question
This is so small I hate to ask, but everytime I type this it just looks odd no matter what way I type it and would like to know how another MT would type this.
If someone has a dull aching sensation or sharp stabbing sensation would you hiphenate (dull-aching sensation) or slash (dull/aching sensation) or just leave it (dull aching sensation)? Thanks for any input to my "stupid" question. 
I would say cecal and S1-S2 is how I format it...nm
Subject: I would say cecal and S1-S2 is how I format it...nm
s
number format
Subject: number format
When transcribing a very large number, "1 million 120 thousand" is it considered more acceptable to use words or just to stick to numbers?
Format question
Subject: Format question
I was hoping someone might be able to give me the rule for this.....Should departments be capitalized? For instance, "she saw University of Virginia orthopedics" Should orthopedics be capitalized or not? I'm always confused about this:)
format question
Subject: format question
I was taught that if the "orthopedics" came after the name of the place, it should be capitalized (UoV Orthopedics). If not, it wouldn't be capitalized(orthopedic department at UoV). Please correct me if I'm wrong, anyone! :)
Punct? format?
Subject: Punct? format?
REVIEW OF SYSTEMS
He is 6 feet tall and weighs 260 pounds. His weight has been stable. No rashes. No problems with his eyes, ears, nose or mouth. Respiratory: he is positive for a smoker, half pack per day, with a smokers cough. Cardiovascular: has a history of hypertension. No GI/GU problems. Musculoskeletal is stated in the HPI. No neurological or hematological disorders.
Is this how this should be put in paragraph form with the Respiratory and Cardiovascular??
Radiology Format ??
Subject: Radiology Format ??
DUPLEX SCAN OF LEGS
Duplex scan of the arterioles system in the legs was performed and results are as follows:
RIGHT LEG: On the right side,
Is this layout correct? or is it
RIGHT LEG no colon? then drop down a line? Thanks
Format rules in MT
Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home. Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way. Problem #1 - HYPERTENSION. The patient is taking lisinopril currently..... or if the doc did not say PROBLEM #1, then you transcribed it 1. HYPERTENSION. Blah, blah, blah. When did this change and become wrong? Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem. Is this in the so-called AHDI BOS2?
IMHO, using the capitalization on the problem is much easier to read, than this...
1. Hypertension. The blah, blah, blah..
2. Diabetes mellitus type 2. Uncontrolled. Not compliant.
Any QAers out there can answer this one for this old school nitpicker?
format that to your accts specs (sm)
Subject: format that to your accts specs (sm)
a.m., AM, whatever your acct likes! LOL
Format for multiple problems
Subject: Format for multiple problems
Can someone show me an example of how to type a report that has multiple problems. The doctor does one problem completely, then goes onto the next one.
It doesn't look right typing HISTORY OF PRESENT ILLNESS, PHYSICAL EXAMINATION twice throughout the report.
Thanks
Format & Capitalization (psychiatric)
Subject: Format & Capitalization (psychiatric)
Capitalize verbal, performance, and full-scale? Should I leave the subtest scores in a vertical list arrangement or use a different format?
On this administration of the Wechsler Adult Intelligence Scale-III, Mr. ___ obtained a verbal IQ of 57 (range 53-63), a performance IQ of 64 (range 59-73), and a full-scale IQ of 56 (range 53-61). These scores fall within the mild range of mental deficiency.
The following scatter of subtest scores was obtained:
VERBAL:
Vocabulary: 2
Similarity: 3
Arithmetic: 2
Digit Span: 3
Information: 3
Comprehension: 2
PERFORMANCE:
Picture Completion: 4
Digit Symbol: 4
Block Design: 4
Matrix Reasoning: 5
Picture Arrangement: 4
All the scores above fall within the mentally deficient range and are relatively even.
Go to format/paragraph and you'll see it. nm
Subject: Go to format/paragraph and you'll see it. nm
In MSWord, go to Format, Font,..
Subject: In MSWord, go to Format, Font,..
Effects, place a check mark next to Subscript.
Time format in BOS 3rd edition
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever.
I do intend to buy my own soon but I have to wait till payday. :(
Much appreciated !
Help with general term...sm
Subject: Help with general term...sm
She says this in the past medical history - negative for any health problems or s/l "renal or anginal disease." But that doesn't make sense as a general term to say.
Thanks!
S/L general ways
Subject: S/L general ways
 Patient is ready to be admitted for outpatient surgery tomorrow for right hemicolectomy. When awakened this morning he felt this sharp pain in his right upper quadrant, started having some nausea *** to upper fever of way over 102. (after nausea is sounds like he says general ways to upper fever..."can that be right)? thanks
general malaise? nm
Subject: general malaise? nm
General anesthesia with the use of an s/l LME?
Subject: General anesthesia with the use of an s/l LME?
What is the general consensus on this....sm
Subject: What is the general consensus on this....sm
20-pack-year smoking history or ????
Thanks in advance.
ps: Tara, if your online, I've got the file you need. I'll zip it and send......
general word help
Subject: general word help
On physical doc says slight s/l cog wheeling or something to that nature to explain upper extremities at the elbow. Any ideas?? Cannot find word.
GET - general endotracheal
Subject: GET - general endotracheal
Yes, that's right. It means in general.
Subject: Yes, that's right. It means in general.
Can a general anesthesia be..
Subject: Can a general anesthesia be..
given in "intravenous intubation"? I thought intubation was only a tube in a hollow organ, like the stomach.
General surgeon does, too. nm
Subject: General surgeon does, too. nm
Format/Grammar/Punctuation Help (psychiatric)
Subject: Format/Grammar/Punctuation Help (psychiatric)
DIAGNOSTIC ASSESSMENT:
AXIS I: Psychosis NOS, schizoaffective disorder, bipolar type versus bipolar I disorder versus a drug induced psychosis, also polysubstance abuse. Should the word versus be transcribed as a slash or another format in this example? Thanks!
Medquist letter format question...
Subject: Medquist letter format question...
I never usually have to type letters so I am unsure of the format. Are we supposed to type the "Sincerely," and are we supposed to indent it?
Thanks!
He dictates in SOAP format so that might look out of place.
Subject: He dictates in SOAP format so that might look out of place.
Time format rules in BOS 3rd edition?
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever is easier.
I do intend to buy my own soon but I have to wait till payday and I'm starting a new company right now that uses that book :(
TIA !
Axis format but employer prevails
Subject: Axis format but employer prevails
I go like so
Axis I
xxxxx
xxxxx
xxxxx
Axis II
Axis III
Axis IV
Axis V
3 months' time is the correct format
Subject: 3 months' time is the correct format
General exam would be fine. (nm)
Subject: General exam would be fine. (nm)
.
This is probably so off the mark, but could it be general mask?
Subject: This is probably so off the mark, but could it be general mask?
general range or gommelin????
Subject: general range or gommelin????
Not able to apply my logic.
Her _____(gommelin / general range) is unchanged and she is pleased with it.
The patient has headaches and also for knee problem. Also not dictating under physical examination.
It's just under and Objective/General section
Subject: It's just under and Objective/General section
SOAP is a really archiac format, rarely used today
Subject: SOAP is a really archiac format, rarely used today
and occasionally used today but rare.....
As q. day is a dangerous abbreviation, the correct format is p.o. daily...:)...nm
Subject: As q. day is a dangerous abbreviation, the correct format is p.o. daily...:)...nm
x
catheter general hear or read it as smi
Subject: catheter general hear or read it as smi
JR5 (Judkins right 5) (JL5 Judkins left 5) etc
Could they be a GM (General Motors) employee? Can't find much else under G's and J's in Flo
Subject: Could they be a GM (General Motors) employee? Can't find much else under G's and J's in Florida. nm
s
I work for a general surgeon who dictates...sm
Subject: I work for a general surgeon who dictates...sm
sestamibi scan on all his parathyroid patients...........
and google to back it up:
Sestamibi Scan for parathyroid disease and Sestamibi x-ray for parathyroid tumors. The Sestamibi scan finds the diseased parathyroid gland.
www.parathyroid.com/sestamibi.htm - 49k - Cached - Similar pages |
Sestamibi Scan for parathyroid disease and hyper-parathyroid disease. The parathyroid Sestamibi scan finds the diseased parathyroid gland and can be used ...
parathyroid.com/Sestamibi-Technical.htm - 65k - Cached - Similar pages |
Hgh quality sestamibi scan shows a single parathyroid adenoma. ... The Sestamibi scan will display the hyperactive gland which is causing ...
www.endocrineweb.com/sestamibi.html - 9k - Cached - Similar pages |
A sestamibi scan of the parathyroid gland is a nuclear medicine procedure which is performed to identify hyperparathyroidism (or parathyroid adenoma). ...
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