Progress Note headings?
Posted By: agrahammt on 2007-09-18
In Reply to: Can you hear Chief Complaint in there? nm - Txczech
Subject: Progress Note headings?
I really want to hear Chief Complaint, but I’m sure he starts with Cardio. Thanks anyway.
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Progress Note headings?
Subject: Progress Note headings?
I can’t hear the “tat” part, but that sure makes sense. I like the cardiovascular, too, except this is talking about GERD - could that be connected to Cardiovascular system?
progress note
Subject: progress note
On this progress note it sounds like the doctor says "blood pressure 167/82, heart rate is 90, resperate 20, T max is 100.8."
Should that be respirations 20, temperature at max 100.8? thanks
progress note
Subject: progress note
thanks so much for your help you are right!!!
progress note
Subject: progress note
thanks for your help!!!
progress note help please!!!
Subject: progress note help please!!!
Blood pressure 167/82. Heart rate is 90, respiratory rate 20, Temperature at max is 100.8. No JVD lungs and expiratory wheezes. There are some rales in the right base. Heart without ** and edema. **120, **3.4, chloride 94, ** 25, glucose 91, BUN 9, creatinine .6, calcium 8.5, white count is 5.7, hemoglobin 8.9 down from 10 yesterday, platelet count 234,000, 6 lymphs, 10 minus 1 basophiles, 7 bands, 76 segs.~~~~ after heart without--it sounds like a extremity then ssss sound. the other sounds like Sims 120. the other sounds like seven and a 3.4. the other sounds like bacum. ANY HELP WOULD BE GREATLY APPRECIATED!!!!
Progress note help
Subject: Progress note help
Heart: Without? lower extremity edema. Sodium 120, potassium 3.4, chloride 94, bicarb 25.
Also, probably should be temperature T-max is 100.8. No JVD. Lungs: End-expiratory wheezes.
progress note help
Subject: progress note help
You are wonderful. I can't thank you enough!!!!!!!!!!
help with progress note
Subject: help with progress note
This pat has a cough and post-nasal drip, as well as GERD
Begins s/l *effuncting* nausea and abnormal liver enzymes. This could be a title or description of the nausea, but I can’t find anything.
Then,
s/l *Cardiovicular*. She reports the nausea has resolved. . . . has post-nasal drip .. .cough is not constant. Reflux is under good control
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Progress Note: Heart without ?, Help please
Subject: Progress Note: Heart without ?, Help please
Heart without _____ (s/l extra absoftness) without edema.
Also in same report, dictator says:
Urine shows 5-10 red cells, occasional white cells, moderate bacteria, negative glucose, negative
_____ (s/l glucoside esterase).
Does anyone know what those 2 blanks might be? I see “glucosylceramidase assay” in the Stedman’s Lab Words book, but I don’t hear that in the dictation.
I would appreciate any help at all.
s/l careic? lesions. dental progress note
Subject: s/l careic? lesions. dental progress note
progress note--right lower lobe pneumonia
Subject: progress note--right lower lobe pneumonia
this is what the doctor is saying--"She has been on half-normal. Her (saline/sodium) drop will change to normal saline of 50cc an hour." in the second sentence of this I am not sure if he is saying saline or sodium? any help?
Headings
Newbie here. If a doc dictates a laboratory data and lists lab values, then talks about x-rays and ekgs, do you include that in the lab section or make a separate heading for x-rays and ekgs (what would you title that section?). Thanks for any info.
Headings
Subject: Headings
I am transcribing a History & Physical Examination Report (Neurology)
The headings confuse me terribly. What would the heading be for the following:
Orientation and language are normal fundi with sharp disks bilaterally.
I have the following:
NEUROLOGIC: Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on tandem walk she really has difficulty with that. She does not line up her toes easily and loses her balance very easily with that. (Is that the correct heading?)
Also, does anyone have a good website for determining headings?
headings
Subject: headings
Thanks so much. Does it get better?
Headings
Subject: Headings
If in a report , broke into 2 sections.. MRI of the Right leg then left..
and said
History
Technique
then
Technique
History
would it be a good idea to switch order for consistancy?
not an answer on headings, but
Subject: not an answer on headings, but
Sorry, I don't have a quick answer about your headings, but I wanted to let you know that your first sentence should be 2 sentences: Orientation and language are normal. Fundi with sharp disks bilaterally. (Fundi and disks/discs refer to the eyes, nothing to do with orientation or language.) Good luck with the headings - I still get confused sometimes on them too if I don't have a specific format to follow.
If QA has no recommendations, you don't have to have headings in there at all. Just do the report
Subject: If QA has no recommendations, you don't have to have headings in there at all. Just do the report
s
verbatim, abreviations, and headings?
Subject: verbatim, abreviations, and headings?
typing verbatim. In headings PREOPERATIVE DIAGNOSIS and POSTOPERATIVE DIAGNOSIS, when doc says same for POSTOP. Do you type same when typing verbatim?
Headings are allowed to be added.
Subject: Headings are allowed to be added.
It would look weird without a heading. Thanks.
History & Physical Headings
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
History & Physical Headings+1>?
Subject: History & Physical Headings+1>?
Thanks. One more question. What headings do you add if not transcribed to the H & P?
Making progress
Subject: Making progress
He said the first 3 letters again and spelled them:
I, B as in Bictor (meaning V as in Victor), F Laboratory.
So now we have IVF icksee Laboratory.
making a little progress
Subject: making a little progress
with this one, thanks to your answers... still hearing something like "Pradus" but instead of obturate, was saying on THE RIGHT. definitely NOT piriformis or sure does not sound like it, then goes on to gluteus medius and maximus.
It could be. If there is failure to progress. sm
Subject: It could be. If there is failure to progress. sm
I had to have an emergency C-section and they ruptured my membrane. They used this crochet hook looking thing. So it could possibly be assisted or even abrupt.
Depends on what your QA says, but I separate out the entities and only use headings if
Subject: Depends on what your QA says, but I separate out the entities and only use headings if
s
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.
Interstital tissue and pelves need headings?
Subject: Interstital tissue and pelves need headings?
Spleen: The spleen has a thin fibrous capsule. Malpighian bodies are indistinct the sinusoids are moderately widened.
Liver: Sections of the liver show a thin fibrous capsule. Multiple small fatty vacuoles are noted in the cytoplasm. Portal spaces are fairly small in size. There is mild widening of the sinusoids in the central zones.
Kidneys: The kidneys have a thin capsule. The cortices that show glomeruli of normal appearance. The tubules are not remarkable.
Interstitial tissue showed no note worthy change. The pelves are not remarkable.
In this instance.. does the interstitial tissue and pelves need their own headings.. or is this correct?? Thanks
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Work under progress on Word Board...
Subject: Work under progress on Word Board...
You may experience posting problems on Word Help Board only for next couple of hours.
Sorry for the trouble,
MTStars Administration.
diagnosis for operation includes intrauterine pregnancy at term, failure to progress and sm
Subject: diagnosis for operation includes intrauterine pregnancy at term, failure to progress and sm
and fetal s/l "a-sink-qua-sism".
noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy
Just wondering if there is any general rule about transcribing noteworthy.
Also, status post; status-post.
Thank you.
Op note ref. SM
Subject: Op note ref. SM
http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note
? pulse ox 99% on room air which is normal per ______ interpretation.
ER note thanks
Subject: ER note thanks
Thanks, practically sure it was per the ER physician reading. So, will be ready for next time!
At the end of OP note, he says
Subject: At the end of OP note, he says
what sounds like "mick" instrument and needle count.
On another, says "sponge, _____and instrument" and that sounds like "lab". Any clues are appreciated. Thank you!
OP note help please sm...
Subject: OP note help please sm...
mild (s/l-fibulations-) with changes on the surface of the condyle
Of note..... I want
Subject: Of note..... I want
to thank everyone so much for all the help I have received on this website since I have become an MT. Bless everyone of you. I hope one day to help those also asking questions as you all have me.
Op note
Subject: Op note
Dictator says: Local Xylocaine 1% anesthesia 'arfate' cannulated.
What is the 'a' word?
me again - same op note :(
Subject: me again - same op note :(
The wound was irrigated and rough edges were S/L RASSED. 
op note help
Subject: op note help
Using an up-biting basket and a S/L 405 shaver a medial meniscectomy was performed.
TIA!
OP NOTE HELP
Subject: OP NOTE HELP
The iliotibial band was then split inline with the incision and retracted anteriorly and posteriorly with a _____ bow. s/l charming.....
The procedure is a cemented bipolar hemiarthroplasty left hip.
OP NOTE STILL
Subject: OP NOTE STILL
Should have went further in the note...sorry...another blank is
Attention was directed to the proximal femur, which was prepared with a box-cutting chisel, _____ canal finder and a trochanteric router this sounds like "chauney"
ESL help with op note
Subject: ESL help with op note
She says: With forceps and a S/L barpotta knife the lesion was excised. (This is excision of a lid nodule).
have another on this same note - sm
Subject: have another on this same note - sm
Bilateral elbow rheumatoid arthritis. The left side is more advanced with (s/l)'spectus articulusdamage than appears on the right side
op note help
Subject: op note help
This is an excision of a breast nodule. Two questions:
1. The area was prepped with s/l Cloraprep
2. The needle was grasped with an S/L Alice clamp
See note below
Subject: See note below
This is the context of the report. It sounds just like Waddellian. He says this quite a bit and it stumps me every time....
PSYCHIATRIC: The patient was alert and oriented x3 with a somewhat depressed and scattered mood, being very jumpy and quickly agitated by minimal movements or pressures in various areas such as supporting the leg while doing musculoskeletal motor examination for neurologic examination. The patient definitely showed some ____________________ symptoms through our examination. When the idea of psychiatric help in this manner was brought up in this case, the patient seemed almost excited to know this was a coming event.
op note help
Subject: op note help
This is a partial medial meniscectomy and synovectomy.
large s/l type 1 plica present - is type 1 correct?
This was resected back to a stable configuration using an s/l oslite shaver or 8 inch shaver (he mumbles) ???
op note help
Subject: op note help
This is for an amputation of the left hallux.
Upon induction of IV sedtion a total of 10 ml of 0.5% Marcaine plain was infiltrated in a S/L Mayo block type fashion.
Mayo block???
note, no h on the end.
Subject: note, no h on the end.
x
Op note help
Subject: Op note help
ORIF surgery: Intraoperative s/l FLORA showed excellent alignment of the implants.
Note put above
Subject: Note put above
what does it mean when she dictates "note, put above..." before a sentence? i'm confused.
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