Patient with right ankle sprain. Plan: Gave please sm
Posted By: Barbara on 2008-01-21
In Reply to:
Subject: Patient with right ankle sprain. Plan: Gave please sm
s/l "Murray ice compression device". Thanks for any help.
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sprain of the ankle
Subject: sprain of the ankle
There was some question of a s/l 'dorsed chip of the vendicular' ??
Thanks
s/l Lawsten cast for ankle sprain (nm)
Subject: s/l Lawsten cast for ankle sprain (nm)
s/l miconal taping. Patient with a sprain of the ACL.
Subject: s/l miconal taping. Patient with a sprain of the ACL.
:-)
Patient with pneumonia - plan for... s/l R-cat consult??
Subject: Patient with pneumonia - plan for... s/l R-cat consult??
Patient in for Plan B birth control. sm
Subject: Patient in for Plan B birth control. sm
P: Pt is placed on oral bc. Discussed missed dose protocol. Reviewed ACHES (doc spells this out).
Thanks.
Recommendation and plan in patient with metastatic melanoma
Subject: Recommendation and plan in patient with metastatic melanoma
To maintain DENSE intensity for neutropenic fever precautions, we have ordered Nuelasta 6 mg subcutaneous injection on 10/18.07.
For the life of me, I can't figure out dense intensity. Any ideas?
Patient with foot ulcer. Under plan, "She has been switched to 1/2-strength s/l Day-gin SM
Subject: Patient with foot ulcer. Under plan, "She has been switched to 1/2-strength s/l Day-gin SM
solution daily.
Patient is status-post s/l ex-plan of the left total knee. nm
Subject: Patient is status-post s/l ex-plan of the left total knee. nm
Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Sorry, tried to help. Have a nice weekend.
perhaps sprain/strain? nm
Subject: perhaps sprain/strain? nm
sprain/strain - definitely!
Subject: sprain/strain - definitely!
inguinal sprain?
Subject: inguinal sprain?
patient has a hx of a right inguinal sprain
He was given a soft-tissue injection. He went to orthopedics and is in a wheelchair now.
syndesmotic sprain? sm
Subject: syndesmotic sprain? sm
ortho dictation is my favorite but they do use their own lingo. Sorry you are having a hard time. That is why we are all bald-headed!!!
Word help pls - s/l strainular sprain
Subject: Word help pls - s/l strainular sprain
Left shoulder impingement versus rotator cuff tear
most likely just some strainular sprain with some impingement in that left shoulder.
strain and/or sprain (is my suggestion) nm
Subject: strain and/or sprain (is my suggestion) nm
.
Status post right long MCP joint sprain with s/l shroud ligament tear.
Subject: Status post right long MCP joint sprain with s/l shroud ligament tear.
:-)
Left wrist sprain with probable TFCC degenerative tear and s/l bore bursitis?
Subject: Left wrist sprain with probable TFCC degenerative tear and s/l bore bursitis?
could be volar, does that make sense????
Thanks you two...gave up on this one :(
Subject: Thanks you two...gave up on this one :(
nm
What you gave was what I was looking for...
Subject: What you gave was what I was looking for...
... he dictated that upon examination of the incision site there was no ____. I gave the wrong definition , but you gave me the right word. Thanks again!
I gave up...
Subject: I gave up...
No Suboxone either. What a horrid report. Thank you so much for trying to help. Maybe I can just get nailed by QA again. I got critical feedback for misspelling a word that does not even exist yesterday. The doc said it, I spelled it and put a hyphen in between "dis" and the rest of the word, and QA wanted no hyphen. I can't do ANYTHING right of late (very long story including the mtquestions situation).
Thanks again for trying, though!!
Plan
Subject: Plan
CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.
I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.
Plan help please!
Subject: Plan help please!
 I am a new, and need some help. after the doctor says plan he lists the medications he has prescribed. He does not number them and I am used to them saying medications and then listing (1, 2, 3) Do they usual do that? Should I leave it like he says it? Example:
PLAN:
Ecotrin 1 p.o. b.i.d. with meals. Keflex 500 mg p.o. q.i.d. for 4 days.. Follow-upl with me within the next 10 days.
thanks!
Plan help please!
Subject: Plan help please!
That all depends on the QA person reviewing the report.
I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).
I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.
Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you
Do you have to have a plan?
Subject: Do you have to have a plan?
Where I work, if they don't say "plan", they don't get a "plan".
That's what I plan to do.
Subject: That's what I plan to do.
I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
It would help if you gave a little more information
Subject: It would help if you gave a little more information
:
I have tried and tried - if they gave him Suboxone - I
Subject: I have tried and tried - if they gave him Suboxone - I
was trying to make it into Narcan or naloxone - I have the most trouble with Asians because they emphasize the wrong syllable and the consonants are totally blurred. I almost called my daughter - who is a pharmacist.
Ha! I hate it so much I gave away the
Subject: Ha! I hate it so much I gave away the
only psych reference book I had. It was the old Stedman's one that had psych and neuro mixed together. HATED that book, LOL.
Not only is psych boring, but a lot of it is actually drug rehab, and those patients' problems are 95% self-inflicted out of pure foolishness.
That is what they gave me to dry my milk.
Subject: That is what they gave me to dry my milk.
its not a psych drug.
You gave a really good s/l. nm
Subject: You gave a really good s/l. nm
nm
I gave him Permacath, but still if anyone
Subject: I gave him Permacath, but still if anyone
out there can clear this up, I would greatly appreciate it. I have used Permacath and PermCath on many occasions and not sure which is right anymore.
That's the answer I already gave, though.
Subject: That's the answer I already gave, though.
Thanks...I gave her a blank...
Subject: Thanks...I gave her a blank...
She was clearly saying "saline walked" rather than saline washed or locked. I think she was distracted (dictating at 3 a.m.) and just threw a wrong word in there, so I left her a blank.
Thanks so much for your help!!!
Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan
1. Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago. I asked him to repeat it, but he forgot. We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly. He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
assessment&plan help!
Subject: assessment&plan help!
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
- Bilaterally arm numbness.
- Nausea.
- Health maintenance recommendations.
PLAN:
- Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion. She will be referred for MRI with cervical spine. Patient may need EMG to further access her numbness.
- Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn. She does have chronic nausea and this may be a sign of stomach reflux. She will be tried on Nexium 40 mg one q.d. Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night. We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism. ___ problem health maintenance and in regards to increase her exercise and changing her diet. Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram. When she follows up to see me we will discuss potential options for colon screening. Patient is to follow-up with me in approximately 1 month time.
assessment and plan
Subject: assessment and plan
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
starts plan
Subject: starts plan
it starts the plan then says ??? flonase 2 sprays each nostril
Sounds like a plan to me!!
Subject: Sounds like a plan to me!!
Thanks!!
s/l her-plan-jet-ick lesions
Subject: s/l her-plan-jet-ick lesions
s/l her-plan-jet-ick lesions in the mouth and throat
this is a 17 month old with excessive drooling and fever.
that sounds like a plan
Subject: that sounds like a plan
nm
Yes it was and I could hear it clearly since you gave me the word!
Subject: Yes it was and I could hear it clearly since you gave me the word!
the definition you gave is correct (sm)
Subject: the definition you gave is correct (sm)
i wondered how you got the incorrect spelling to go with it. must be google huh? that is a good example of google being incorrect. it finds all kinds of things, even wrong ones.
but a good definition!!! 
my pea gave out on me very early today LOL
Subject: my pea gave out on me very early today LOL
ewww yeah I bet that wasn't a whole lot of fun lol
If he already gave you a couple, then it would be 'all other...' nm
Subject: If he already gave you a couple, then it would be 'all other...' nm
s
I have a 'normal' the hospital gave to me...
Subject: I have a 'normal' the hospital gave to me...
for cataract surgery and it has super-sharp blade in it. ...don't know if that helps ya or not.
wait - you just gave the answer...
Subject: wait - you just gave the answer...
palpable peripheral edema - when you said *pulp* I realized they sometimes use *palp* - as in palpable (but usually they say *palp* in regards to blood pressure)
Think maybe it's palpable peripheral edema?
I bet that was it. Not familiar at all, I gave up and blanked it.
Subject: I bet that was it. Not familiar at all, I gave up and blanked it.
I agree with the explanation rc gave.
Subject: I agree with the explanation rc gave.
I have never seen L5-S1 expanded. However, the MTSOs that we use ask us to clarify format questions every now and then. I would have to say ask for clarification.
well, you gave such a good clue
Subject: well, you gave such a good clue
sometimes we over-think things, huh? i really love this board to get other's opinions and help -- be lost without it....
sorry gave you wrong 1...the actual
Subject: sorry gave you wrong 1...the actual
chlorambucil....
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