Not a typical heading, but how about "question etiology." nm
Posted By: Lifer on 2007-01-06
In Reply to: S/L? SG ETIOLOGY? - c-hav
Subject: Not a typical heading, but how about "question etiology." nm
x
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- S/L? SG ETIOLOGY? - c-hav
- Not a typical heading, but how about "question etiology." nm - Lifer
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"question of pancreatic...." n/m
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Formatting when doctor dictates "question..."
Subject: Formatting when doctor dictates "question..."
Dictated: "Patient was prescribed question Pyridium"
How would I transcribe this? Would I type, "Patient was prescribed Pyridium?"
Thanks in advance!!!!!!
how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
s/l neb typical vastia
Subject: s/l neb typical vastia
Might want to ask if this is typical for this doc. Maalox sometimes
Subject: Might want to ask if this is typical for this doc. Maalox sometimes
s
well, it's definitely not typical like a first thought- sm
Subject: well, it's definitely not typical like a first thought- sm
Because the patient is given an antibiotic. I can't rule out atypical but it seems unlikely because I just can't hear all those syllables.
rude post - no name - typical
Subject: rude post - no name - typical
 Thank goodness for the nice people out there.
2 more s/l *staria* typical to Cushings and *understeindial*
Subject: 2 more s/l *staria* typical to Cushings and *understeindial*
 Patient evaluated for obesity and weight gain.
I do not see any *starea* that are typical with Cushing disease.
I am going to check her A1c, testosterone, DHE, sulfate, and *understeindial*
Thanks.
S/L? SG ETIOLOGY?
Subject: S/L? SG ETIOLOGY?
At the end of this H&P doc says a heading S/L "ST ETIOLOGY" or "SG ETIOLOGY" or "HISTORY ETIOLOGY" Any ideas? It is the last section of the report after IMPRESSION and includes his recommendations. The patient is complaining of gaseous indigestion.
S/L? ETIOLOGY?
Subject: S/L? ETIOLOGY?
Thanks, I'll listen again. ETIOLOGY is part of a heading. S/L "ST ETIOLOGY"
etiology?...nm
Subject: etiology?...nm
xx
Just a guess, etiology? nm
Subject: Just a guess, etiology? nm
!
etiology? morphology?
Subject: etiology? morphology?
x
Pig etiology ?? Please see message
Subject: Pig etiology ?? Please see message
Has coronary artery disease with single bypass. Has pacemaker. Patient has a prosthetic aortic valve, s/l pig etiology.
Thanks for replying. Would they say pig etiology?
Subject: Thanks for replying. Would they say pig etiology?
brain etiology? WAG here. nm
Subject: brain etiology? WAG here. nm
Etiology of his end stage renal disease
Subject: Etiology of his end stage renal disease
Etiology of his end stage renal disease, vasculopathy, is not entirely clear from the charting of s/l "al boo".
Etiology of hematemesis is due to peptic ulcer disease or ***.
Subject: Etiology of hematemesis is due to peptic ulcer disease or ***.
He's mumbling it and I can only hear *losum* at the end. I think it's some sort of bacteria. TIA!!!!!!
s/l "fashus" (long a sound) versus ischemic etiology
Subject: s/l "fashus" (long a sound) versus ischemic etiology
Can anyone help with this? It sounds like "fashus"
Cecal inflammatory change, consideration of ________ versus ischemic etiology, potential for neoplastic infiltration of the cecum should be considered
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
Thanks.
Under what heading would you SM
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
TIA
EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
EKG: EKG today show no ST wave changes.
Heading?
Subject: Heading?
This is for a psych. consult. After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.
I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records. Past Medical History, yes, but not the other. Any ideas?
Oops, used same heading, need help
Subject: Oops, used same heading, need help
Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".
Thanks
IV abbreviated in heading
Subject: IV abbreviated in heading
Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?
under abdomen heading
Subject: under abdomen heading
s/l "the PICC was created" or "the tic was created"
Angie
Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?
I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with
s
I think doc left heading out sm
Subject: I think doc left heading out sm
He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.
What would be asymmetrical here?
I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm
One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
A lot of facilities use the heading
Subject: A lot of facilities use the heading
"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?
Just wondering under what physical exam heading other MTs put this finding under.
TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.
I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they
want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?
I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
Sorry, this should have been under heading Physical Examination.
Subject: Sorry, this should have been under heading Physical Examination.
In my opinion, should be spelled out in heading
Subject: In my opinion, should be spelled out in heading
nm
Not the OP, but a skin prep would be under a different heading
Subject: Not the OP, but a skin prep would be under a different heading
s
Heading in exam? COR: Cardiac etc.
Subject: Heading in exam? COR: Cardiac etc.
Make INFORMANT a new heading.
Subject: Make INFORMANT a new heading.
CHIEF COMPLAINT:
Lump on the side of the neck.
INFORMANT:
Mother and patient.
i would say Examination and Evaluation needs to be put as a heading.
Subject: i would say Examination and Evaluation needs to be put as a heading.
just my thoughts.
I use IMAGING as the heading for EKG, CAT scans, etc.
Subject: I use IMAGING as the heading for EKG, CAT scans, etc.
Hi, Julia, capitalize when used as heading, otherwise, SM
Subject: Hi, Julia, capitalize when used as heading, otherwise, SM
it is part of the sentence and should not be capizalized, somewhat like saying that patient is coming in for a complete physical exam, would not need to capitalize.
Not saying COR as a heading? for heart exam etc? nm
Subject: Not saying COR as a heading? for heart exam etc? nm
H&P exam heading questions
Subject: H&P exam heading questions
doctor is dictating in paragraph form on the PHYSICAL EXAMINATION part sometime subheadings are givenhere it is: His vital signs his pulse is 112, his respirations are 14, his blood pressure is 157/86. His general appearance is he appears quite comfortable, his face is flushed. Non-toxic and no respiratory distress. His neck is supple, he demonstrates full motion of his neck without pain s/l orshe finds tenderness to palpatation. I believe this should be typed this way: VITAL SIGNS: Pulse is 112, respirations are 14, blood pressure is 157/86. GENERAL APPEARANCE: He appears quite uncomfortable, his face is flushed. Non-toxic and no respiratory distress. NECK: His neck is supple, he demonstrates full range motion of his neck without pain Or she finds tenderness to palpation. I would ask my instructors about these, it seems like every time I get graded each assignment it different.
Dee tra emphasis? heading under neurologic..
Subject: Dee tra emphasis? heading under neurologic..
Under physical exam, neurologic, this is given as a subheading....
s/l dee tra emphasis:
sounds like should be under "neurologic" heading
Subject: sounds like should be under "neurologic" heading
brain freeze..in ROS: what heading would polyphagia go under? thank u
Subject: brain freeze..in ROS: what heading would polyphagia go under? thank u
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.
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