Objective: Head is held straight with no s/l "lift or lisp"
Posted By: ubby_g on 2009-04-24
In Reply to:
Subject: Objective: Head is held straight with no s/l "lift or lisp"
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s/l supermed The foot was held in neutral ankle dorsiflexion with the toes straight and the FDCFHL
Subject: s/l supermed The foot was held in neutral ankle dorsiflexion with the toes straight and the FDCFHL
were "pinned with supermed." Thanks again for your help.
Please help with objective . . .
Subject: Please help with objective . . .
The wound has been cleaned by the nurse, and it looks very good. s/l Pride flesh is starting to form.
TIA for any suggestions!
Objective portion
Subject: Objective portion
does this make sense to anyone
GU and rectum s/l farum are rectal sphincter muscle tone
a few hints for you - when doing the objective
Subject: a few hints for you - when doing the objective
findings, when doc says, for instance, "In general, the patient is..." you are putting that under the "general" subheading, so you don't need to repeat the "in general" part - meaning it would just be GENERAL: The patient is....
same with the skin exam that you have there - if doc is saying "skin is warm and dry," and you are putting it under the "skin" subheading, it should just be "SKIN: Warm and dry" ...and so on.
also, in the HEENT section, it should be "sclerae" and "conjunctivae" - doc is referring to the plural form here.
Does that make sense? This is the way it's usually done, but you'll need to follow the instructions you've been given, of course.
It's just under and Objective/General section
Subject: It's just under and Objective/General section
Oh thanks everyone. I have held onto this waiting for this response.
Subject: Oh thanks everyone. I have held onto this waiting for this response.
via hand-held nebulizer (nm)
Subject: via hand-held nebulizer (nm)
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though. 
his Coumadin be held s/l transilay prior to this
Subject: his Coumadin be held s/l transilay prior to this
nt
OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
Subject: OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
diagnosis: Cerumen impaction.
Maybe "hand" treatment for a hand-held nebulizer? nm
Subject: Maybe "hand" treatment for a hand-held nebulizer? nm
s
held suction? or something about "held sucks" which would be succinylcholine.
Subject: held suction? or something about "held sucks" which would be succinylcholine.
x
Yep, Keeping the area clean with a peri-bottle (a hand-held squirt bottle) can be soothing and help
Subject: Yep, Keeping the area clean with a peri-bottle (a hand-held squirt bottle) can be soothing and help prevent infection.
short for perineal
how I keep it straight
Subject: how I keep it straight
neuro- is a combining form referring to a system of an anatomical part, be it the entire body or the system of specific an anatomical part,
neural -- Relating to any structure composed of nerve cells or their processes, or that on further development will evolve into nerve cells
Since the foramen (foramina-pl) is a specific structure, the combining form would be incorrect.
can someone please get me straight
Subject: can someone please get me straight
on CONN or KHAN catheter ???
How about straight leg raising
Subject: How about straight leg raising
does that sound like it now?
That is what they usually say.
Straight leg raising
Subject: Straight leg raising
STL STRAIGHT leg raising?
Subject: STL STRAIGHT leg raising?
,
straight leg raise, maybe?
Subject: straight leg raise, maybe?
S/L Straight kokers?
Subject: S/L Straight kokers?
This OP report is killing me today! It is in regards to a C-section and I am not very firmiliar with OP reports..the dictator is saying "the lower edge of the fascia was _______ (masked?) with s/l straight kokers?????
Any ideas??
It's SLR = straight leg raising
Subject: It's SLR = straight leg raising
straight leg raising sign........
Subject: straight leg raising sign........
.
Straight from the Bard site.
Subject: Straight from the Bard site.
are available in 4 and 5 French single-lumen and 5 and 7 French dual-lumen. Bard, RadPICC and RadSTIC are registered.
I have also seen it 7F, 8F pigtail catheter, etc. NO HYPHEN. 
straight leg raise test s/l
Subject: straight leg raise test s/l
Sag and flip tests are normal?
TIA! 
straight vs smart quotes
Subject: straight vs smart quotes
Do you use straight quotes or smart quotes in Word?
Straight quotes are just the " mark,
Subject: Straight quotes are just the " mark,
Smart quotes are where they look like commas, first is "upside" down and last "right side up"
Straight quotes are just the " mark,
Subject: Straight quotes are just the " mark,
Smart quotes are where they look like commas, first is "upside" down and last "right side up" You can sent them in Word in the autocorrect section under autoformat as you type.
clamped with straight Kochers probably - nm
Subject: clamped with straight Kochers probably - nm
or could be - grasped with straight Kochers
Subject: or could be - grasped with straight Kochers
s/l 'R&N' clamps, uses both straight and curved during hysterectomy. Thanks! nm
x
What's not helpful? Looks like the poster got it straight from a dictionary!
Subject: What's not helpful? Looks like the poster got it straight from a dictionary!
Got it! Lasegue's Sign (which is straight leg raising)
Subject: Got it! Lasegue's Sign (which is straight leg raising)
x
for a straight consult rep and not real letter
Subject: for a straight consult rep and not real letter
but it DOES depend on the client profile/preference like the other poster said.....I get this format all the time in REAL consult reports (not letters) and I just type *Dear Dr. Smith* - I have just seen your patient....blah blah (can usually go under reason for consult or HPI) and then do my headings as dictated.
Good question, though!
You're right, MT50, thanks for setting me straight!...nm
Subject: You're right, MT50, thanks for setting me straight!...nm
SLRT (straight leg raising test)?? nm
Subject: SLRT (straight leg raising test)?? nm
nm
yep! Figure-4 and straight-leg-raise test.
Subject: yep! Figure-4 and straight-leg-raise test.
x
can you hear straight leg raising if he's talking fast?
Subject: can you hear straight leg raising if he's talking fast?
x
straight leg raise and Kram's (sp?) sign negative
Subject: straight leg raise and Kram's (sp?) sign negative
sentence is
Straight leg raising and s/l Cram/Kram sign are negative bilaterally.
thanks so much in advance
The dictation after just went straight into the impression, so I didn't include it. nm
Subject: The dictation after just went straight into the impression, so I didn't include it. nm
nm
Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
Subject: Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
hardcore verbatim you have to leave it as is, whether it looks ugly or not. I know, I really don't like it when they abbreviate left and right, leave words off sentence structures so they can speak faster and get it over with.
Pix of Joan of Arc show her with both arms straight overhead holding
Subject: Pix of Joan of Arc show her with both arms straight overhead holding
s
The straight s/l "gold" reamers were used to ream the proximal femur. NM
Subject: The straight s/l "gold" reamers were used to ream the proximal femur. NM
nm
grafts are either straight or curved, so perhaps saying, "U-type" (describing the shape)? prob
Subject: grafts are either straight or curved, so perhaps saying, "U-type" (describing the shape)? probably not UTI... nm
waisting - or narrowing, like your waist is supposedly smaller (ha!) compared to straight up/down. N
Subject: waisting - or narrowing, like your waist is supposedly smaller (ha!) compared to straight up/down. NM
.
I removed the posterior aspect of the skull outer table with a s/l pencio 1 and straight curette
Subject: I removed the posterior aspect of the skull outer table with a s/l pencio 1 and straight curette
Skin tag is clamped using a straight s/l Kelly (? Kelley). Cannot find in surgical word book.
Subject: Skin tag is clamped using a straight s/l Kelly (? Kelley). Cannot find in surgical word book.
CT head/esl doc
Subject: CT head/esl doc
CT brain showed central s/l "cortical and cerebellar" involutional changes, old infarct in the territory of the anterior s/l "BR" of the left middle cerebral artery.
Not sure on the wording in first one. I am coming up with a blank on the second.
Ha ha! This doc is exactly enough of a bu**head to say this... (sm)
Subject: Ha ha! This doc is exactly enough of a bu**head to say this... (sm)
Thanks! I bet that's it!
CT of the head
Subject: CT of the head
The patient has a history of a remote-appearing lacunar infarct within the left frontal lobe adjacent to the left frontal horn of the left lateral ventricle and mild periventricular white matter chronic small-vessel disease on CT scan of the head without contrast.
I am just concerned with the ..periventricular white matter chronic small-vessel disease
How would you type this? the doctor just says it without any pausing.
ahhhhhhh!
s/l CVC of the head was done???
Subject: s/l CVC of the head was done???
Head. Thank you!
Subject: Head. Thank you!
xx
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