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L4-5 if that is what is dictated NM

Posted By: Angela on 2008-09-16
In Reply to: L4-5 or L-4/5? - mt

Subject: L4-5 if that is what is dictated NM

xxx


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Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
Subject: Just as you have it if that's what was dictated. If "one fourth" was dictated, sm

it would be 1/4 pill or one fourth of a pill.


Def an 'N' dictated - Diabetes unsure of - no PMH dictated
Subject: Def an 'N' dictated - Diabetes unsure of - no PMH dictated


We type it as dictated, if dictated
Subject: We type it as dictated, if dictated

c spine we transcribe C-spine, if cervical then cervical spine.
for PA- DICTATED BY PA's name...nm
Subject: for PA- DICTATED BY PA's name...nm

x
Dictated 427 rbc's and 58 rbc's
Subject: Dictated 427 rbc's and 58 rbc's


what was dictated; if not, do it your way...NM
Subject: what was dictated; if not, do it your way...NM

x
what was actually dictated?
Subject: what was actually dictated?


This was just also dictated under sm
Subject: This was just also dictated under sm

past surgical history, but STILL sounds like dragon pack. This is going to drive me nuts!!!!
exactly as dictated.
Subject: exactly as dictated.

x
Thanks! He only dictated one N
Subject: Thanks! He only dictated one N

Thank you!
If that is what he dictated, then that is
Subject: If that is what he dictated, then that is

what you use, even though it is usually esophagogastroduodenostomy; however, maybe duodenum has been removed so therefore could be.
Just like he dictated it.
Subject: Just like he dictated it.

x
Yes, as dictated. (nm)
Subject: Yes, as dictated. (nm)

.
I'm not sure if this is one or two drugs being dictated. SM
Subject: I'm not sure if this is one or two drugs being dictated. SM

I will refill her Armour Thyroid and her s/l modratic and estrace


or maybe it s/l modratic in estrace??? any clue what this is ???


do it, regardless if dictated differently...nm
Subject: do it, regardless if dictated differently...nm

x
Whichever way it was dictated. nm
Subject: Whichever way it was dictated. nm

x
it depends on how it is dictated...sm
Subject: it depends on how it is dictated...sm

6600 (no comma) or 6.6 if they say it that way; if they say 6.6 thousand then you give them *6.6 thousand*


 


give them what was dictated as the pt probably...nm
Subject: give them what was dictated as the pt probably...nm


It's okay. I'd transcribe it as dictated. nm
Subject: It's okay. I'd transcribe it as dictated. nm

/
You don't add in mg or mcg, etc. unless it's dictated. The docs know
Subject: You don't add in mg or mcg, etc. unless it's dictated. The docs know

s
lasered, as dictated
Subject: lasered, as dictated

.
SGOT dictated: 4-2-6 T: 426 or 4.26
Subject: SGOT dictated: 4-2-6 T: 426 or 4.26

SGOT dictated: 4-2-6 T: 426 or 4.26. same with SGPT dictated 1-1-9 T: 119 or 1.19
I have only used galactorrhea as dictated. nm
Subject: I have only used galactorrhea as dictated. nm


I don't think that would be it because the dr who dictated it is a urologist.
Subject: I don't think that would be it because the dr who dictated it is a urologist.

Earlier in the note, the dr said he did not get an s/l osbot or ozbot appt.
Complete hx not dictated
Subject: Complete hx not dictated

Thanks! Kept your info for future reference. Endo doc just dictated as part of hx; did not elaborate, so not sure.
Never heard it dictated but (sm)
Subject: Never heard it dictated but (sm)

I have heard of some hollistic remedies that include a clorox soak of the feet for yellow nails however normally the docs order Lamisil (terbafine hydrochloride). Just my two cents sorry I couldn't be more help.
five-way CABG if that is what he dictated. nm
Subject: five-way CABG if that is what he dictated. nm

xx
I use rule of 2-3 min. per dictated min. (nm)
Subject: I use rule of 2-3 min. per dictated min. (nm)

x
I always type it the way you have it if that's the way it's dictated. sm
Subject: I always type it the way you have it if that's the way it's dictated. sm

Of course, go by your account specifics. If you can change it, some do. I always just type what they say and it keeps me out of trouble. :)
I would just type as dictated. nm
Subject: I would just type as dictated. nm


That's all I can think of too, but the labs were not dictated.
Subject: That's all I can think of too, but the labs were not dictated.


It was most always dictated to me under abdomen.
Subject: It was most always dictated to me under abdomen.


Leave as dictated...sm
Subject: Leave as dictated...sm

I've seen them that high before. You might see transaminitis in the diagnosis or something like that.
No dosage dictated
Subject: No dosage dictated

He doesn't dictate a dosage. Only problems he had dictated were:

hematuria
benign positional vertigo
pancreatitis
Idiopathic thrombocytopenia purpura

I appreciate your help!
I would leave it as dictated,
Subject: I would leave it as dictated,

x
What was dictated just prior to that?
Subject: What was dictated just prior to that?

.
i would type as dictated.
Subject: i would type as dictated.

x
No - most likely means what he dictated. nm
Subject: No - most likely means what he dictated. nm

x
Type whatever he dictated.
Subject: Type whatever he dictated.

x
I think it is when you add words to what was really dictated? NM
Subject: I think it is when you add words to what was really dictated? NM

xx
I would use it if dictated - see message
Subject: I would use it if dictated - see message

I find it on NIH site and American Journal of Physical Medicine and Rehab. I trust NIH.
Would tend to do a dictated
Subject: Would tend to do a dictated

All dictators have their own style (they use particular phrases etc) I would tend to give them what they want.  Some may say first diagonal branch, some  may have M1 or M2 or (marginal 1 branch and marginal 2 branch.)
No, D means dictated....as in
Subject: No, D means dictated....as in

D is what is dictated so you T transcribe this....

decubiti dictated and you should transcribe decubitus
Leave as dictated.
Subject: Leave as dictated.

x
I'm with you, I type what is dictated. sm
Subject: I'm with you, I type what is dictated. sm

It is not my place to decide what the doctor means. I am not in any way offended by what he/she dictates.
You are correct, pus-like is not the same as pussy.
If they say the F word, I type the word, not asterisks in place of letters, because it's a direct quote from the patient. I do not change direct quotes.
Anybody who is offended by typing a word is putting way too much of their personal life into their work.
Changing what is dictated is not always appropriate
Subject: Changing what is dictated is not always appropriate

even if you are offended by profanity. If the doc you are transcribing has a quote in it, you have to type as dictated or it is not a quote. If the physician is using profanity that has nothing to do with what the patient actually said, then some clients require you to change the words, because it is inappropriate otherwise.

My stance on this is just this. If it is a quote, don't change it, because it changes the integrity of the document. Whether you are offended or not, these medical records also serve as legal documents. You must keep that in mind. Just because you are offended is not a reason to change the words.
No, you type it as dictated.
Subject: No, you type it as dictated.


he probably dictated 'antihypertensives'....nm
Subject: he probably dictated 'antihypertensives'....nm

nm
I type it as dictated.
Subject: I type it as dictated.

x
Just type it as dictated as it can mean more
Subject: Just type it as dictated as it can mean more

x
transcribe as dictated...sm
Subject: transcribe as dictated...sm

"neuralgic pain" would be preferred over "neuralgia pain" if you have the ability to edit on the account; otherwise, give them what they dictate =) (best term to use would have been "neuroPATHIC pain" anyway!) =)