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Need opinions or facts

Posted By: mandiemt on 2007-11-16
In Reply to:

Subject: Need opinions or facts

Most docs dictate possesion for Hodgkin's lymphoma, Meckel's cavity, Gerota's fascia, Morison's pouch, etc.  You get the picture.  All of my references have these without possession.  What is the standard for transcribing?  I was told at one point to leave off the 's and type as referenced.  Do you agree?


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FACTS study
Subject: FACTS study

Baby is having a FACTS study.  I know what it is but was wondering if anyone knew what FACTS stands for.  I have been trying to find this FOREVER.  Thanks in advance
Just stating the facts....that's all......nm
Subject: Just stating the facts....that's all......nm


Substantive: important, serious or related to real facts
Subject: Substantive: important, serious or related to real facts


opinions please (sm)
Subject: opinions please (sm)

Wondering what most people type for dosing units in the millions:


3 million units or 3,000,000 units


From what I see in BOS II, it can be typed either way.  I just typed 3,000,000 units thinking it may be a little more clear on a medication list, but now I am second-guessing, so I am looking for opinions on this.  Thanks


I have 2 opinions on this --
Subject: I have 2 opinions on this --

1) Miralax is generally given 17 g - half would 8.5 g.  That one grabs me more than the abbreviation issue.


2) g is an acceptable abbreviation for grams, but a lot of clients prefer it written out when used alone - much like the word liter when used alone.  It can sometimes be difficult to discern in the report.  If your client has no preference, I would continue to use g and just chalk it up to the QA's preference. 


Opinions are what the board is here for..
Subject: Opinions are what the board is here for..

nm
opinions - how do you all type
Subject: opinions - how do you all type

this -  the dictator says the nodule was FNA'd or I&D'd, etc.  It just seems awkward.


 


Think I figured it out, but would like opinions.
Subject: Think I figured it out, but would like opinions.

I've never heard this, but I've only recently started typing GYN reports.

Patient has bacterial vaginosis. Doc is saying --- MetroGel 0.75% one application s/l p.v. q.h.s. x5 nights.

Stedman's abbv lists p.v. as by way of vagina, so that makes sense? Would just like to know if anyone has heard this. Thanks.
I need opinions on formatting. SM
Subject: I need opinions on formatting. SM

The patient was seen by Dr. John Smith of the cardiology service.


OR


The patient was seen by Dr. John Smith of the Cardiology Service.


This always messes me up!  I've done it the second way for many moons, but I'm training a new girl who says according to the BOS, I'm wrong.  Just wondering how everyone else does it.


 


Opinions please - This doesn't seem right...
Subject: Opinions please - This doesn't seem right...

Patient prescribed prednisone 5-mg, 6-day taper. Doesn't that seem like a low dose of prednisone to do a taper?
I'm sure there will be differing opinions..
Subject: I'm sure there will be differing opinions..

but I'm going to go out on a limb and say PL simply means posterolateral.
Opinions needed on my tweaking ... sm
Subject: Opinions needed on my tweaking ... sm

Here's my tweaking:   I think it looks okay except for the last sentence.  Can anyone help me make that last sentence look better?  Thank you.


 


Dear xxxx :


 


I am pleased to write a letter of recommendation for XXX who is applying to your program.  XXX spent a week with me in my internal medicine office this past summer.  He is currently a student at XXX and has decided on a career in a medicine.  In the process of starting his medical career, xxx has spent time with multiple physicians to show that he is serious about a career in medicine.  He has excellent personal skills, as you will see when you interview him. 


 


During the time I spent with xxx  he asked intelligent questions and showed a genuine interest.  His thought process seemed both logical and rational during our discussions.


 


Based on my experiences with x,  I recommend highly that he be accepted in your training to become an xxx physician.  I believe he has all the makings of good physician, intelligence hard-working, motivated, and personal. 


 


 


Opinions needed See MSSG
Subject: Opinions needed See MSSG

 


 


Question: would you put "Romberg negative.  No pronator drift.  Gait is normal." under extremities or neuro?    Thanks


 


EXTREMITIES:  No clubbing, cyanosis, or edema.  Distal pulses are 2+ and equal throughout.  Romberg negative.  No pronator drift.  Gait is normal.


 


NEUROLOGIC:  Cranial nerves II-XII are intact.  DTRs are 2+ and equal throughout.  Romberg negative.  No pronator drift.  Gait is normal.


Thanks a million. Opinions at this point even help!
Subject: Thanks a million. Opinions at this point even help!


need opinions on the correct way to type this
Subject: need opinions on the correct way to type this

The patient has no discharge drainage or pus.


Initially I thought "drainage, discharge" with the comma but does it make sense without the comma? 


opinions please attained/obtained
Subject: opinions please attained/obtained

I have a doc who keeps saying hemostasis was attained (spells it).  He is ESL - I think you OBTAIN hemostasis.  Am I wrong?
More opinions needed. 2 people are disagreeing here. TY
Subject: More opinions needed. 2 people are disagreeing here. TY


Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the ti
Subject: Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the time.