Meds and dosages scare me, so when in doubt...
Posted By: Hayseed on 2008-02-25
In Reply to: sm - newbie working
Subject: Meds and dosages scare me, so when in doubt...
I always blank/flag it. 
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I agree with Hayseed...meds and dosages scare me, too. However...sm
Subject: I agree with Hayseed...meds and dosages scare me, too. However...sm
You might find assurance in the fact that (according to QuickLook) Lortab is only available with 500 along with the 5, so the 500 might be understood. But, I would flag if you are unsure.
That can happen on meds for a.m. and p.m. dosages, but if you are concerned, is it possible to leave
Subject: That can happen on meds for a.m. and p.m. dosages, but if you are concerned, is it possible to leavea a QA note just for the facility?
mEq (the only way I have ever seen it and have looked also everywhere on dosages)
Subject: mEq (the only way I have ever seen it and have looked also everywhere on dosages)
DOSAGES- how to type out?
Subject: DOSAGES- how to type out?
"He will also add vitamin D to his regimen at 2 to 4,000 units per day."
How should I type this? 2-4,000? 2,000-4,000? 2 to 4,000? I want it to be right.
Need help with how to write dosages (sm)
Subject: Need help with how to write dosages (sm)
Subject: By AAMT rules, need help with period with drug values. (sm) Is this right? 1 gm 0.1 mg 1 mg
I was taught that it was 1.0 mg but doc wants it to be just 1 mg and 1 gm. Help. Thanks.
no speciality. final diagnosis was uti. these meds were admit meds, only hist was hypertension
Subject: no speciality. final diagnosis was uti. these meds were admit meds, only hist was hypertension
Does not matter. All dosages are singular.
Subject: Does not matter. All dosages are singular.
All dosages are singular. 10 cc was injected...
Subject: All dosages are singular. 10 cc was injected...
drug dosages listed with no mg
Subject: drug dosages listed with no mg
Is it acceptable to type drug dosages with the number but not the unit of measure. For example Zocor 10 every night. I believe this may be confused with 10 pills instead of mg. What's acceptable on a verbatim account?
Folate dosages....high?
Subject: Folate dosages....high?
Resident says folate 100 mg via PEG and also folate 1 g via peg. That's a lot, isn't it?
Hematology - know your chemotherapy and dosages well, same anatomy. n/m
Subject: Hematology - know your chemotherapy and dosages well, same anatomy. n/m
Trust us. Docs never give dosages with the word sm
Subject: Trust us. Docs never give dosages with the word sm
"chemotherapy." It makes no sense as there are hundreds of medications (where you would hear dosages) that comprise chemotherapy. Would you rather be corrected by people who are not paid to help you, or would you rather your QA catch a blunder like this? Up to you.
Medication dosages, QA marking wrong both ways!
Subject: Medication dosages, QA marking wrong both ways!
Good afternoon everyone. I'm in need of some second opinions please. When typing medication dosages, I have always transcribed them the same way for the last 12-1/2 years. For example, Lortab 5 mg q.4h. p.r.n. pain.
I have worked for the same company for a little over two years now and have never had QA say anything about this until last month, when I got a QA audit marking it off and changing it to Lortab 5 mg q. 4h. p.r.n. (with a space between the q. and the 4h.) I thought okay, maybe I've been transcribing it incorrectly all lthis time and a new QA person picked up on it. It happens, no big deal. 
So, I started transcribing it their way with the space, as in q. 4h. and didn't think anything more about it. Yesterday, I get another audit. This time, I get dinged for typing it the way they wanted it the last audit q. 4h. with the space with a note stating it should be q.4h. with no space (the way I had been typing it).
 Now, I know they have been messing with all of the MTs big time lately, making changes daily from everything to hours, pay, policies, and procedures for vacation, days off, etc. You name it, they've been doing it, and I really think they are trying to either find a reason to fire some of us or drive us to the point of insanity until we quit, but despite the games, I still want to make sure I'm doing my job correctly. If I've been doing something wrong, I would like to correct it ASAP, except now I have no idea which one is correct.
Sorry for the long, drawn out post, but I'm totally confused now and beyond frustrated. Now, I'm questioning myself on everything, and I have no idea which way is correct as far the space or no space with the medication dosages. Thank you for taking the time to read my question and rant. I would appreciate any and all opinions on how you all transcribe this! 
need help w/2 drugs, s/l thermadon and s/l knee-po-tir? They are just in a list no dosages or usage
Subject: need help w/2 drugs, s/l thermadon and s/l knee-po-tir? They are just in a list no dosages or usage
doubt
Subject: doubt
_____ (Evos) of a 40-year-old female who comes in to the office for follow up on chronic.....
You are without a doubt - sm
Subject: You are without a doubt - sm
a very unhappy person. I feel very sorry for you.
Any doubt
Subject: Any doubt
on vitals or med doses...ALWAYS A BLANK. :-)
equivocal - no doubt about it.....*LOL*
Subject: equivocal - no doubt about it.....*LOL*
Well, I doubt that would help her diet!!
Subject: Well, I doubt that would help her diet!!
I would - but I doubt they'd listen
Subject: I would - but I doubt they'd listen
If you're QA, though, I can nominate you for QA of the month! You deserve it.
Strongly doubt it
Subject: Strongly doubt it
nm
grammar doubt
Subject: grammar doubt
today for routine (follow up or followup) of hypertension.
grammar doubt
Subject: grammar doubt
follow up
doubt with radiology again
Subject: doubt with radiology again
Bony _____ (s* ---- tion) projects the distal right of the radial styloid process, which does not appear to be posttraumatic.
CT Brain doubt
Subject: CT Brain doubt
A 5-mm-thick _____ obtained through the brain with intravenous administration of contrast.
THANKS-don't you hate it when you doubt yourself?
Subject: THANKS-don't you hate it when you doubt yourself?
In degrees of ROM or in end range or ROM? I doubt sm
Subject: In degrees of ROM or in end range or ROM? I doubt sm
it is Dupuytren etc. nm
Thanks for replying. You confirmed it for me so no doubt now.
Subject: Thanks for replying. You confirmed it for me so no doubt now.
Ct abdomen and pelvis doubt
Subject: Ct abdomen and pelvis doubt
multiloculated or ____ (simi subtrated) cyst in the pancreatic map.
Doubt with cervical myelogram
Subject: Doubt with cervical myelogram
Dictating in 2 position:
1. _____(codstone) bone graft is in excellent position.
2. HIs ____(po*city) of bone formation along the edges of _____(c*stone) graft, which is unexpected in more cortical nature.
No, I doubt it since grip strength was 35/50..
Subject: No, I doubt it since grip strength was 35/50..
something else starting with a T that is only 11-12 pounds.
Using a question mark to indicate doubt or uncertainty sm
BOS says:
Use an ending question mark to indicate doubt or uncertainty.
Sometimes, particularly with diagnoses, a question mark is placed before a
statement in order to indicate uncertainty.
Placement either before or after the questionable material is acceptable, but
do not place the question mark both before and after.
Ex:
His cholesterol levels were high normal (or minimally elevated?).
D: Diagnosis: Angina question mark
T: Diagnosis: Angina?
or Diagnosis: ?Angina.
not Diagnosis: ?Angina?
Note: There is no space after the question mark in ?Angina.
=)
Rennie
www.renesue.com
I doubt highly that a stricture or lesion would
Subject: I doubt highly that a stricture or lesion would
improve a patient's nutritional status., but rather do the complete opposite. I think the physician meant to dictate "GI" physician since he/she mentioned the dysphagia in the dictation, which is also a common place for strictures or lesions to develop.
Client preferences rule here. If in doubt, sm
Subject: Client preferences rule here. If in doubt, sm
here's what I've always done:
He was given a do-not-resuscitate order.
I think my high school English teacher would prefer it thusly;)
He was given a "do-not-resuscitate" order.
Like Txczech said, sometimes these are bolded and capitalized to alert treating physicians of patients' wishes, similar to allergy statements. Client preference, again.
Unless you know for sure that the client does not have a special order called the Do-Not-Resuscitate Order, lowercase it. (I think this is what you might have been considering.)
Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again
Subject: Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again. nm
c
Doubt you give 15 refills for narcotics.
Subject: Doubt you give 15 refills for narcotics.
x
Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
Subject: Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.
Subject: I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.
Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something lik
Subject: Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something like coronary obstruction artery "something" syndrome...? Just can't get it :( THanx though!
It's too late to tell you to leave a blank. Doubt "os finder." nm
x
Can find Nitro CR and Nitro-Bid Plateau in 6.5 mg dosages. They MIGHT be saying the generic form
Subject: Can find Nitro CR and Nitro-Bid Plateau in 6.5 mg dosages. They MIGHT be saying the generic form
s
I doubt it, as appendiceal is relating to the appendix and cystocele relating to the bladder.
Subject: I doubt it, as appendiceal is relating to the appendix and cystocele relating to the bladder.
Two meds I need help with
Subject: Two meds I need help with
These meds s/l fatazadime and metroinozol....any suggestions?
meds
Subject: meds
1. Spiriva ?
2. Don't know - sorry.
meds
Subject: meds
If the patient has COPD and Spiriva fits, maybe the second medication is Xopenex?? Just a guess.
meds help please sm...
Subject: meds help please sm...
(s/l-Kaylor-) and (s/l-Theosol-)
Here is the PMHX and other meds tp is on..
Past Medical History: Hypertension, rheumatic fever age 12, osteoarthritis of the knees, temporal arteritis.
Medications: Lexapro, Topamax, Nexium, metoprolol, Caylor, Fiasol, prednisone 5 mg for temporal arteritis, Neurontin 300 mg for controlling her periauricular pain after the biopsy, Xanax 0.25, baclofen 10 mg for her neck, OxyContin over the past year and a half 20 mg for her knees.
meds help please sm..
Subject: meds help please sm..
s/l-Elnoran drug for "bladder."
MEDS
Subject: MEDS
FULFURI
Meds help
Subject: Meds help
s/l 'griburide' - Thanks for the assistance. = )
meds
Subject: meds
List of meds, not sure if she is stumbling over this: s/l Adicade
Patient has Lupus and anemia.
meds again
Subject: meds again
Same patient as below with Lupus and anemia: medication s/l Crissal 
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