No, I cannot confirm. I have some personal notes
Posted By: pc on 2008-02-23
In Reply to: Can you confirm the spelling for me? - MTDays
Subject: No, I cannot confirm. I have some personal notes
that I make and had Segund in them.
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Nurses' notes or nurse's notes or nurses notes?
Subject: Nurses' notes or nurse's notes or nurses notes?
I am so confused on this one. I have typed it several different ways over the years. Do I really need to put any apostrophe in there at all? Thanks!
Nurse's notes reviewed or nurses notes reviewed? nm
Subject: Nurse's notes reviewed or nurses notes reviewed? nm
x
what is your source? personal opinion?
Subject: what is your source? personal opinion?
x
ahh, it is a personal issue - then take it private!
Subject: ahh, it is a personal issue - then take it private!
XX
Client or personal preference
Subject: Client or personal preference
You have several choices here that are correct. You can put E:A reversal, E/A reversal, or E to A reversal. If no client preference, your pick - all are correct.
Some accounts want no personal info
Subject: Some accounts want no personal info
at all in the report, others want pertinent people listed. It depends on the facility/account.
Personal History is correct
Subject: Personal History is correct
nm
My personal favorite is "aspirational pneumonia." :)
Subject: My personal favorite is "aspirational pneumonia." :)
x
Personal opinion, I hyphenate it as tib-fib fracture
Subject: Personal opinion, I hyphenate it as tib-fib fracture
Just personal for me, but I have always typed it Sitzmark study
Subject: Just personal for me, but I have always typed it Sitzmark study
D: personal history of colon polyps
Subject: D: personal history of colon polyps
That's exactly how it was dictated. While all this stuff is "personal," am I missing something here?
Can you please provide the sentence? Or is question of a personal nature?
Subject: Can you please provide the sentence? Or is question of a personal nature?
x
Personal opinion I would hyphate it as supra-SMAS
Subject: Personal opinion I would hyphate it as supra-SMAS
wild guess s/l personal synovarment syndrome
Subject: wild guess s/l personal synovarment syndrome
Right CMC joint arthrosis and s/l personal synovarment syndrome.
Who specifies no personal info? Type what the dictator says. SM
Subject: Who specifies no personal info? Type what the dictator says. SM
The responsibility is in the hands of the dictator. If he or she dictates it, then give it to them... plain and simple.
Personal opinion, but I would only makes this a "header" within a report if the dictator state
Subject: Personal opinion, but I would only makes this a "header" within a report if the dictator states to do so, otherwise I would just type it verbatim in paragraph format.
Personal opinion but I believe it is distal as in determination (i.e. the dorsalis pedis artery puls
Subject: Personal opinion but I believe it is distal as in determination (i.e. the dorsalis pedis artery pulse can be palpated readily lateral to the extensor hallucis longus tendon on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation.)
Please confirm...
Subject: Please confirm...
Osteomeatal versus ostiomeatal????
Cannot confirm either, but has ICD-9-CM - nm
Subject: Cannot confirm either, but has ICD-9-CM - nm
x
I would confirm (sm)
Subject: I would confirm (sm)
exactly what she is referring to before making the decision to transcribe bilateral. She may mean bimalleolar (ankle) edema. If that were the case, bilateral ankle edema is very different than bimalleolar edema, which would mean 1 foot versus 2. If you can leave it blank and get a response back, that is the best idea. 
op notes
Here is a list from my favorites. Hope they are a little bit helpful. I think they are all still good sites.
Op note sites:
http://www.mt-stuff.com/ent.html
http://mtdesk.com/gen.shtml
http://www.medical-library.org/journals2a/tubal_ligation.htm
http://www.mtdaily.com/samples.html
http://www.nezhat.com/oplap_abst.htm
http://www-personal.umich.edu/~aalin/vitalsigns/contentappendix/cntappsamplenotes.html
op notes
Subject: op notes
I have never encountered such a rule. I don't generally listen to where the dictators want their paragraphs, though. They usually put in way too many. I start a new paragraph after the prep and drape description and a I start a new paragraph for the closing of the wounds. I add new paragraphs when the surgeon is addressing a new area. That's just my style of transcribing. I'm not saying it's the right way to do it. It just makes sense to me and I would think it is easier to read and comprehend that way.
take notes!
Subject: take notes!
Whenever I have to spend a lot of time looking something up, I make sure to write it down. It's worth it.
I don't do op notes! LOL
Subject: I don't do op notes! LOL
thanks - I saw that on google but could not confirm NM
Subject: thanks - I saw that on google but could not confirm NM
Thanks! I just needed to confirm that (n/m)
Subject: Thanks! I just needed to confirm that (n/m)
--
Can you confirm the spelling for me?
Subject: Can you confirm the spelling for me?
Frankly, this was a new term for me in terms of a fracture, and I'm away from my reference books. When I Google it, half of the references come up segUnd and half segOnd, and just wondered if there is a Dorland's kind of confirmation.
Yes. Thank you. I try to confirm before adding
Subject: Yes. Thank you. I try to confirm before adding
thanks - i usually do ER notes so not familiar with that!
Subject: thanks - i usually do ER notes so not familiar with that!
Resources for OP notes?
Subject: Resources for OP notes?
Is there anyone here who does operative notes and gynecology notes who could give me some websites to use for resources? I am on an OB/GYN account and have operative notes. I have trouble sometimes with the specific surgical instrument names and would greatly appreciate any help. Thanks in advance.
Resources for OP notes?
Subject: Resources for OP notes?
My suggestion would be to purchase (if you do not already have)OB/GYN, equipment and surgical word books (Steadman's) my choice and you would be equipped to better perform your job.
OP notes resources
Subject: OP notes resources
I would do that but we are on a tight budget as we just bought a house and are getting in married in september.
Paragraphs in Op notes
Subject: Paragraphs in Op notes
I have noticed that when I transcribe an Op note as the dictator dictates it, starting a new paragraph as dictated...that QA always removes the spacing between the paragraphs.
Is there some rule in transcription that you don't break an op note into paragraphs? The client profile does not say anything about this.
SOAP notes
Subject: SOAP notes
Was wondering if there are any websites out there that gives sample reports for SOAP notes. Just trying to figure out which is the best way to do it with paragraphs between each heading or all scrunched together. Just want to see what is done more of. I realize it might depend on the clinic, dr, hospital, etc, but just want to get an idea.
Thanks Carla
Thanks so much! I'm taking notes!
Subject: Thanks so much! I'm taking notes!
SOAP notes
Subject: SOAP notes
transcribing for 7 1/2 week old child. Dictator states fontanels are flat, sound like "contrapendalence" are normal.
I have parascapular in my notes.
Subject: I have parascapular in my notes.
Think just nurses notes. IMO. nm
Subject: Think just nurses notes. IMO. nm
Nurse's notes..
Subject: Nurse's notes..
An apostrophe shows ownership. :-)
Cannot confirm "chain sutures." Thanks!
Subject: Cannot confirm "chain sutures." Thanks!
dd
I have been told Gilsbaugh but never able to confirm. NM
Subject: I have been told Gilsbaugh but never able to confirm. NM
Can anyone confirm T pod for orthopedic report?
Subject: Can anyone confirm T pod for orthopedic report?
X
Can anyone confirm spelling? encephaloduroangiosynangiosis
Subject: Can anyone confirm spelling? encephaloduroangiosynangiosis
x
Can someone confirm VersaTek staples?
Subject: Can someone confirm VersaTek staples?
TIA!
that is what I thought but just wanted to confirm - thanks! nm
Subject: that is what I thought but just wanted to confirm - thanks! nm
I'm really thinking he messed up *ski,* but can't confirm. Thanks though. nm
Subject: I'm really thinking he messed up *ski,* but can't confirm. Thanks though. nm
nm
s/l vaginal cuff? Can someone confirm this.
Subject: s/l vaginal cuff? Can someone confirm this.
I think it might be Primicon sutures-can anyone confirm?
Subject: I think it might be Primicon sutures-can anyone confirm?
nm
Thanks! Thought so, but helps to have someone else confirm
Subject: Thanks! Thought so, but helps to have someone else confirm
That's what I thought, just hoping someone could confirm it
Subject: That's what I thought, just hoping someone could confirm it
Thanks!
Can anyone confirm or correct this term~
Subject: Can anyone confirm or correct this term~
because I can not find it anywhere. The doc is saying "
Persistent mild pericardial effusion status post pericardial centesis for cardiac s/l "topidnod" secondary to a large effusion.
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