Office visit H&P- Thanks! nm
Posted By: NCMT on 2008-03-17
In Reply to: theres a med called "Proair" its albuterol inhaler. - mt-123
Subject: Office visit H&P- Thanks! nm
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This was an office visit. Thanks
Subject: This was an office visit. Thanks
Context, please! What are you doing - xray, scan, office visit, etc.?
/
Maybe RV for return visit? nm
Subject: Maybe RV for return visit? nm
s
Just guessing... RV as in return visit?
Subject: Just guessing... RV as in return visit?
Just in for a neurosurgery visit, but other meds not associated.
Subject: Just in for a neurosurgery visit, but other meds not associated.
Doc tends to slur a lot, so I may have to flag it.
office???
Subject: office???
Could be..
You don't know my office...
Subject: You don't know my office...
It would appear that not only do they not go by AAMT, but they make it up as they go along. And if there are two rules contradicting each other, better pray the document is not the one they pick for QA.
The patient did have a s/l UDM at the last visit that was positive for opiates.
Subject: The patient did have a s/l UDM at the last visit that was positive for opiates.
Is UDM correct? If so what is spelled out?
If you are saying like dr smith's office
Subject: If you are saying like dr smith's office
would it be John Smith's,MD or would it be John Smith, MD's office? Where would the appostrophe go?
Could it be office appointment?
Subject: Could it be office appointment?
That's it!! Just confirmed via office, too. Thank you!! (nm)
Subject: That's it!! Just confirmed via office, too. Thank you!! (nm)
xx
office note help
Subject: office note help
I am doing a otology office note and the doctor dictates "during his ___ (s/l relic or realick) surgery, there was recurrent cholesteatoma and during dissection, the _____ (s/l flick-plate)became free
EKGs in my office?
Subject: EKGs in my office?
visit this link for options regarding suction cannula
Subject: visit this link for options regarding suction cannula
you can visit this link to see and search for options.
I think you were right, ECG 7-14 was abnormal, today's visit is normal in comparison
Subject: I think you were right, ECG 7-14 was abnormal, today's visit is normal in comparison
Boy with fevers and pain (rheum. visit). He does not have any *tempwella* with ... sm
Subject: Boy with fevers and pain (rheum. visit). He does not have any *tempwella* with ... sm
... the fevers or the presumed joint pains. He does not seem to have any morning stiffness.
Thanks.
Thanks for the help, Im going to flag it for the office to relisten. nm
Subject: Thanks for the help, Im going to flag it for the office to relisten. nm
He says "I did a bi ox today in the office and was 99-100% on room air.
Subject: He says "I did a bi ox today in the office and was 99-100% on room air.
Pediatric rheum visit. Med s/l soyametatine/solumetatine 400 mg daily sm
Subject: Pediatric rheum visit. Med s/l soyametatine/solumetatine 400 mg daily sm
I'm not sure what the med is for, but child has PFAPA syndrome. On my s/l, I hear the end better than the beginning, hence the two different beginnings.
Thanks!
Might just be the History and Physical that's back at the office, or the H&P. nm
Subject: Might just be the History and Physical that's back at the office, or the H&P. nm
s
Would depend on the context. In the office setting, it could be. I don't
Subject: Would depend on the context. In the office setting, it could be. I don't
s
When sis comes to visit she always gets good laughs reading the phobia pages in my Dorland's.
Subject: When sis comes to visit she always gets good laughs reading the phobia pages in my Dorland's.
nm
Thought it had more to do with her sources of information on the patient prior to initial visit. nm
Subject: Thought it had more to do with her sources of information on the patient prior to initial visit. nm
x
Drain was removed at this first postop visit- discontinued makes the most sense. Thanks!
Subject: Drain was removed at this first postop visit- discontinued makes the most sense. Thanks!
Check my spelling--I'm nowhere near my office. Calibri forceps. nm
Subject: Check my spelling--I'm nowhere near my office. Calibri forceps. nm
x
yes it is capitalized; referring to Dr. Smith's specifric office
Subject: yes it is capitalized; referring to Dr. Smith's specifric office
nm
Gals in my office are taking a vote, we are arguing about 7-French SM
Is it 7-French diagnostic sheath. Hypen or no? Driving me bonks, someone clear this up? Many references state different things.
A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for sm
Subject: A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for sm
A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for an R&M C&S which returned unremarkable.
I know what C&S is. What is the R&M????? help please Donna
Maybe 'hold, on call' to hold the patient in the office for the on call xray? nm
Subject: Maybe 'hold, on call' to hold the patient in the office for the on call xray? nm
s
She will follow up with me(v)/will be seen in followup(n); will have a follow-up visit (adj)
Subject: She will follow up with me(v)/will be seen in followup(n); will have a follow-up visit (adj)
x
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