My MD dictates all the time, "perimenopausal symptoms" I can't document. Should I type it
Posted By: What would you do? NM TIA on 2005-10-09
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Subject: My MD dictates all the time, "perimenopausal symptoms" I can't document. Should I type it anyway?
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he is dictating is backwards. I would type it as he dictates...nm
Subject: he is dictating is backwards. I would type it as he dictates...nm
xx
Type it exactly as the doctor dictates, verbatim....nm
Subject: Type it exactly as the doctor dictates, verbatim....nm
nm
To have "the grippe" is an old-time phrase meaning influenza or a severe cold-like symptoms, e
Subject: To have "the grippe" is an old-time phrase meaning influenza or a severe cold-like symptoms, etc. nm
s
Maybe for IBS type symptoms? sm
Subject: Maybe for IBS type symptoms? sm
lactase?
See this link.
http://www.ibsgroup.org/medications
Pt with memory problems. and lots others. s/ Corete cell janka type symptoms. see message.
Subject: Pt with memory problems. and lots others. s/ Corete cell janka type symptoms. see message.
The patient has had weight loss since discontinuation of steroids. The patient and her husband believe that the general improvement in her condition may be related to steroid use, and they point out a recent article in Archives of Neurology in which a channel antibody has been associated with corete cell janka type symptoms.
Yep. Type that all the time. SM
Subject: Yep. Type that all the time. SM
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the normal mechanics of the patellofemoral joint. ...
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yep, type it all the time
Subject: yep, type it all the time
i've never really looked it up, but the docs say it so often i give it to them. my guess is that edema would create a gas in the soft tissues. or, they say something thing interosseous gas --- just my guess, but it's frequently dictated on my radiology reports.
They say that all the time, just type what he said.
Subject: They say that all the time, just type what he said.
x
One-teens is how I type it. Was on QA at the time and was
Subject: One-teens is how I type it. Was on QA at the time and was
Yep, it's a lab profile; I used to type it all the time at my children's
Subject: Yep, it's a lab profile; I used to type it all the time at my children's
nm
I was told at one time to type it as 110s
Subject: I was told at one time to type it as 110s
time to type 1.5 hours of dictation..
Subject: time to type 1.5 hours of dictation..
It usually takes me twice the time to transcribe the work. If the doc is easy and you can go right from one template/document to the next, it should only take you like 4 hours at the most. 10-12 hours is an awful long time. What kind of interruptions are you getting.
I type CT head all the time but I guess it depends sm
Subject: I type CT head all the time but I guess it depends sm
on the sentence and client's preferences. 
Yes, sounds like a made up word, but I type it all of the time.
Subject: Yes, sounds like a made up word, but I type it all of the time.
nm
The symptoms of perimenopause or perimenopausal symptoms. Why not?? nm
Subject: The symptoms of perimenopause or perimenopausal symptoms. Why not?? nm
s
It might be patent. It means open or clear. I used to type radiology and used the term all the time
Subject: It might be patent. It means open or clear. I used to type radiology and used the term all the time.
what time are we using here in mtStars? US time or India time?
Subject: what time are we using here in mtStars? US time or India time?
is it protime, pro-time, or spelled out prothrombin time? also, where did you find it.. i've look
Subject: is it protime, pro-time, or spelled out prothrombin time? also, where did you find it.. i've looked.
xx
with time are you supposed to put the word hour after the time, i.e. 1600 hours
Subject: with time are you supposed to put the word hour after the time, i.e. 1600 hours
nm
that would be two weeks' time. 's is singular (one week's time) and s' is pleural (two
Subject: that would be two weeks' time. 's is singular (one week's time) and s' is pleural (two weeks' time)
nm
pro time, no hypen, two words, as if your typing prothrombin time
Subject: pro time, no hypen, two words, as if your typing prothrombin time
prothrombin time, partial thromboplastin time
Subject: prothrombin time, partial thromboplastin time
?? PTT is partial thromboplastin time, PT is prothrombin time
Subject: ?? PTT is partial thromboplastin time, PT is prothrombin time
so that didn't answer my question at all -- and in fact was incorrect info
2 years' time or 2 year's time- Which is correct?
I put 2 years' time and was marked off on QA.
How can I use something I can't document? nm
Subject: How can I use something I can't document? nm
.
Under PMH. MD dictates: sm
Subject: Under PMH. MD dictates: sm
Status post trauma/repair to patient’s eye.
Would you leave this as is with the slash or change it? I am permitted to change things when necessary. Thanks.
What do you do when the doc dictates sm
Subject: What do you do when the doc dictates sm
... and I gave the patient 50 "mikes" of whatever medication. One said to spell it m-i-q-u-e-s, one said to use m-i-k-e-s, and one hospital said not to use it at all. So, does it stand for micrograms? Should we use slang? Aghh! Help, please.
I would put as doc dictates..sm
Subject: I would put as doc dictates..sm
if he says "calcium one every day" I would not input the q.d., but I would expand it as "calcium, one tablet every day." jmo and how I have been doing it with no complaints.
Exactly the way MD dictates it
Subject: Exactly the way MD dictates it
If the patient could see anything at all (I had one today where the patient could see 20/1760), then the MD would have given the value, but when there is nothing there, you just type nothing. I have a verbatim account, but even if I didn't, I still would not change it to 20/0 as that lone "0" could be mistaken as something else.
If a Dr. dictates
Subject: If a Dr. dictates
"posterior tib", meaning posterior tibial artery, do you type the abbreviation or go ahead and type out tibial?
if that's the way he/she dictates it...then yes I would. nm
Subject: if that's the way he/she dictates it...then yes I would. nm
xxx
One Weeks' Time or One Week's Time
Subject: One Weeks' Time or One Week's Time
Which one is correct?
Thanks! 
fourth time she has used this she is saying on-cora..each time in the..
Subject: fourth time she has used this she is saying on-cora..each time in the..
paragraph she talks about Omega 3 fatty acid maybe she means Omacor, but is saying Oncora instead of Omacor?? any ideas on this one?? thanks
I agree - we all do it from time to time - we try to make something else out of it
Subject: I agree - we all do it from time to time - we try to make something else out of it
nm
PT or Pro time stands for prothrombin time
Subject: PT or Pro time stands for prothrombin time
Three month's time or three months' time? TIA!
Subject: Three month's time or three months' time? TIA!
cannot document Valacet.......nm
Subject: cannot document Valacet.......nm
just be able to document the source where you got it from
Subject: just be able to document the source where you got it from
x
It's very hard to document,
Subject: It's very hard to document,
but it is bolgerized, after a doctor whose last name is Bolger.
s/l paracoccygeal.....cannot document...sm
Subject: s/l paracoccygeal.....cannot document...sm
Pain originates out of the s/l paracoccygeal region up to her neck.
TIA
I can't document in a book either, but
Subject: I can't document in a book either, but
crura of the diaphragm actually makes some sense. I am thinking this is repair of a hiatal hernia or a small hole that would lead to a hiatal hernia. Myself, I would give the doctor the word and use it.
Thanks. I couldn't document it anywhere. sm
Subject: Thanks. I couldn't document it anywhere. sm
What's your reference?
Yeah, sorry. He says it clearly twice, but can't document. Thx.
Subject: Yeah, sorry. He says it clearly twice, but can't document. Thx.
I can document histiocarcinoma, but
Subject: I can document histiocarcinoma, but
not of the uterus, not sure about this at all, hate to tell you wrong. Need to find annabanana on here and check with her,she would probably know. Histiocytoma I might buy, but I am not even sure about that. Histio cancer to me just does not gel.
sorry...its the "q" size I can't document. nm
Subject: sorry...its the "q" size I can't document. nm
ureteropelvocalyxes ? Cannot document
Subject: ureteropelvocalyxes ? Cannot document
The doctor dictates
Subject: The doctor dictates
His aortic valve appeared well-(s/l seated). I found some examples like that, but am unsure of certainty and spelling accuracy? Thank you in advance for any help.
Think that one is bad? my md dictates things like this...sm
Subject: Think that one is bad? my md dictates things like this...sm
I used a small, tiny, little Q-tip .... and he doesn't want me to change it. Bizarre!!!
I have a doc that dictates same thing
Subject: I have a doc that dictates same thing
mine means adenosine thallium
I leave it as whatever the doc dictates.
Subject: I leave it as whatever the doc dictates.
It's not my job to keep them politically correct.
Do I change it when he dictates cc? nm
Subject: Do I change it when he dictates cc? nm
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