My workplace allows lab abbrvns to stay in diagnoses, too. nm
Posted By: wanderer on 2007-10-18
In Reply to: Which is correct? - Wondering
Subject: My workplace allows lab abbrvns to stay in diagnoses, too. nm
s
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- Which is correct? - Wondering
- My workplace allows lab abbrvns to stay in diagnoses, too. nm - wanderer
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Nothing about that on dangerous abbrvns list, so keep it
Subject: Nothing about that on dangerous abbrvns list, so keep it
s
stay with "guaiac"...
Subject: stay with "guaiac"...
From what I can remember working in the lab (which was a while ago), normally guaiac and heme stools are pretty much done the same way (usually smeared onto 3 cards), both looking for blood in the stool for anemia, colon cancer, etc. I would say doc is repeating herself only because one system is gastrointestinal and the other is rectal, and just keep typing what she says.
would you hyphenate stay-at-home mom?
Subject: would you hyphenate stay-at-home mom?
A good reason to stay away from that doc! nm
Subject: A good reason to stay away from that doc! nm
.
Maybe _-0 chromic stay suture? nm
Subject: Maybe _-0 chromic stay suture? nm
Patient is to stay on a low-__ diet. Not salt. S/l low-fall nm
Subject: Patient is to stay on a low-__ diet. Not salt. S/l low-fall nm
,,
Foley was maintained throughout the stay secondary to s/l co-poor-ify?
Subject: Foley was maintained throughout the stay secondary to s/l co-poor-ify?
crossed stay sutures and figure-of-8 tension band?
Subject: crossed stay sutures and figure-of-8 tension band?
There are also exceptions to "latin grammar" do you say mooses? Some words stay the same, eve
Subject: There are also exceptions to "latin grammar" do you say mooses? Some words stay the same, even pleural, there are always exceptions...nm
and medical language is a specific language all unto itself. Check MEDICAL references, legitimate ones, Dorland's dictionary has been the foremost in the industry, please do not cause a fellow MT to make an error that could cause her problems with her doctor/company. But I am all for helping!
If it was dictated like that & you can leave abbrvns in, then leave it
Subject: If it was dictated like that & you can leave abbrvns in, then leave it
s
I think it is only the diagnoses that need....
Subject: I think it is only the diagnoses that need....
to be spelled out. This part is more like the plan.
diagnoses
Subject: diagnoses
Axis I - VI are not arms of one diagnosis, but of many diagnoses, in different systems and considerations. They include psychiatric diagnoses, functional diagnoses, physical illness diagnoses, etc., etc.
Diagnoses...
Subject: Diagnoses...
Croup and bronchitis.
Procedures: nasogastric tube feed and OPM study. Also says that OPM study indicated silent aspiration.
Any other diagnoses?
Subject: Any other diagnoses?
diagnoses
Subject: diagnoses
Debility.
Dementia with acute confusional state.
Abrasion to shoulder.
Metastatic disease.
Dehydration.
End-stage COPD.
Arthritis.
SIADH.
Hypokalemia.
Hyponatremia.
Bowel obstruction, etiology undetermined.
Urinary tract infection.
Septic condition of blood.
diagnoses
Subject: diagnoses
Diagnoses as follows:
paroxysmal atrial fibrillation, end-stage renal disease, Lown-Ganong-Levine syndrome, hypertension, hypopituitarism, acromegaly, hyperparathyroidism, hypothyroidism, insulinoma.
does that help?
Diagnoses....
Subject: Diagnoses....
Hypertension, chronic edema, hypothyroidism, pacemaker placement, mitral valve prolapse, DVT, hyperlipidemia, GERD, proteinuria, right-sided heart failure
No, see diagnoses. Thanks.
Subject: No, see diagnoses. Thanks.
1. Acute left chest pain.
2. Esophagitis.
3. Coronary artery disease.
4. Hypertension, severe.
5. Probable renal artery stenosis.
6. Peripheral vascular disease.
7. AKI.
8. Malnutrition.
9. Anemia.
Two diagnoses nm
Subject: Two diagnoses nm
k
are these diagnoses...
Subject: are these diagnoses...
correct? He rambles them all together, not sure if I am correct with what I am hearing.
DIAGNOSES:
1. HARDWARE PAIN, RIGHT SECOND METATARSAL FUSION WITH A HISTORY OF DEEP INFECTION AFTER HAMMERTOE PROCEDURE, RIGHT SECOND TOE
2. PAIN AFTER KNEE REPLACEMENT
3. PAIN, LEFT FOOT
tia.
is this 2 or 3 diagnoses?
Subject: is this 2 or 3 diagnoses?
DIAGNOSES:
1. LEFT KNEE LATERAL MENISCUS TEAR
2. OSTEOCHONDRAL DEFECT
3. RIGHT KNEE DEGENERATIVE JOINT DISEASE
Not sure if Right knee degenerative joint disease should be number 3. tia.
I should have put the diagnoses which are..
Subject: I should have put the diagnoses which are..
1. GOUTY ARTHROPATHY
2. NEURALGIA PAIN
3. FAT PAD ATROPHY
Would it still be hallux shoes and also if so would Hallux be capitalized? Thanks for your help.
on diagnoses -diseases
Subject: on diagnoses -diseases
DISCHARGE DIAGNOSES
- Relapse acute myelomonocytic<soundslike> leukemia.
- Severe pancytopenia due to bone marrow hypopasia secondary to cancer chemotherapy.
- Sepsis, possibly due to staphylococcus lubdenensis.
- Ogroshong<soundslike> catheter exit site infection.
- Hypocholemia.
Any diagnoses for the patient? nm
Subject: Any diagnoses for the patient? nm
s
Doc says in diagnoses list...
Subject: Doc says in diagnoses list...
Status post PCIA with stents in the left anterior descending.
Can't find PCIA. Did find PCI - percutaneous coronary intervention. Or does he mean PTCA?
Are they receiving TPN? Or do you have any diagnoses? nm
Subject: Are they receiving TPN? Or do you have any diagnoses? nm
s
Any diagnoses on this patient? nm
Subject: Any diagnoses on this patient? nm
s
Yes, it's discharge diagnoses-First
Subject: Yes, it's discharge diagnoses-First
one is enterobacter septicemia due to line infection.
could definitely fit in with diagnoses and problems
Subject: could definitely fit in with diagnoses and problems
Thanks so much!
Have a great day!
any diagnoses or dosage?
Subject: any diagnoses or dosage?
one diagnosis or more diagnoses
Subject: one diagnosis or more diagnoses
DIAGNOSIS: INTERNAL DERANGEMENT, RIGHT KNEE
TEAR OF THE LATERAL MENISCUS, RULE OUT MEDIAL MENISCUS TEAR
EARLY DEGENERATIVE ARTHRITIS
Not sure if this is all one diagnosis or more. Any ideas. The only thing that I think makes it sound to be one is because he doesn't mention which knee for any of the others. If it is one how would you punctuate. Sorry for so many questions but I am confused..tia.
Final Diagnoses
Subject: Final Diagnoses
1. Congestive heart failure.
2. Cellulitis, right leg.
3. Cardiomyopathy.
4. Morbid obesity.
Do you know the diagnosis or diagnoses?
Subject: Do you know the diagnosis or diagnoses?
Normally, you don't number diagnoses
Subject: Normally, you don't number diagnoses
within an axis. We do this.
Axis I: xxxxx
xxxxxx
Axis II: xxxxx
etc. Each diagnosis is on a separate line, but not numbered.
The SSA was given in a list of diagnoses. sm
Subject: The SSA was given in a list of diagnoses. sm
Totally occluded bilateral SSA stenosis. Patent s/l "profundal" arteries.
Also in list is of diagnoses is the following....Coronary artery bypass graft and "SVG to LAD", "SVG to OM"... not sure on these abbreviations... can you tell I am completely lost....
It's a list of discharge diagnoses...
Subject: It's a list of discharge diagnoses...
DKA, then s/l Right leg varicose, then obesity. He says it later in the report and it definitely s/l varicose.
listed in diagnoses, no sentence
Subject: listed in diagnoses, no sentence
.
Was that a typo? I've never had VI diagnoses, only 5.nm
Subject: Was that a typo? I've never had VI diagnoses, only 5.nm
I believe the are 2 separate diagnoses and would transcribe as such.
Subject: I believe the are 2 separate diagnoses and would transcribe as such.
.
whats the diagnoses?---this ending could be a lot of
Subject: whats the diagnoses?---this ending could be a lot of
diff meds, first one that comes to my mind is
fluoxetine
Can you look in the pt's diagnoses for clues? Think your PT/INR phrase
Subject: Can you look in the pt's diagnoses for clues? Think your PT/INR phrase
s
context, sentence? - diagnoses?....nm
Subject: context, sentence? - diagnoses?....nm
can you give the patient's diagnoses?
Subject: can you give the patient's diagnoses?
Any past history or diagnoses? nm
Subject: Any past history or diagnoses? nm
s
any diagnoses or problem list?
Subject: any diagnoses or problem list?
Differential diagnosis or diagnoses? nm
Subject: Differential diagnosis or diagnoses? nm
senescent changes (fyi no abbrev in your diagnoses too...) nm
Subject: senescent changes (fyi no abbrev in your diagnoses too...) nm
I would keep it as you have it, (3 diagnoses) just put periods at the end of each sentence. :)
Subject: I would keep it as you have it, (3 diagnoses) just put periods at the end of each sentence. :)
3 diagnoses, the 2nd and 3rd caused by Diabetes...nm
Subject: 3 diagnoses, the 2nd and 3rd caused by Diabetes...nm
nm
I would say in this instance if dictator is referring to diagnoses, sm
Subject: I would say in this instance if dictator is referring to diagnoses, sm
it probably is hyper given that he is diagnosed with hypertension but is on meds for that. his bp is low today so he wants to decrease the norvasc as it is over working. the patient isn't diagnosed with hypotension, it is only hypo due to medication dosaging.
All my university docs tell me it is diagnoses, so I have used that for 8 years.
Subject: All my university docs tell me it is diagnoses, so I have used that for 8 years.
nm
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