Pupils equally reactive to light, they do not always dictate the whole exam abbreviation, they ..sm
Posted By: Cyndiee on 2008-11-19
In Reply to: He's using the "PERL" as a word for trick or shortcut. NM - me
Subject: Pupils equally reactive to light, they do not always dictate the whole exam abbreviation, they ..sm
do not always examine all aspects on PE. Hope this helps!
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HEENT: Pupils Equal, round, reactive to light and accomendation and ______ intact. thank you
Subject: HEENT: Pupils Equal, round, reactive to light and accomendation and ______ intact. thank you
Pupils reactive 4 to 3 ????
Subject: Pupils reactive 4 to 3 ????
4-3? 4:3? New one to me!
Could the doc be trying to say radiant light as in using a little flashlight to check pupils.
Subject: Could the doc be trying to say radiant light as in using a little flashlight to check pupils.
xx
...reactive to accommodation and light? Usually heard as 'to light and accommodation.' nm
Subject: ...reactive to accommodation and light? Usually heard as 'to light and accommodation.' nm
s
there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
Subject: there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
if that's it? This is usually dictated when they don't want to list the entire medication list so refer to the MAR that is in the chart.
Ear exam...good bony light
Subject: Ear exam...good bony light
The next word is what I don't understand. This is in the HEENT exam. The statement is: TM's are flat with good bony light ___. Is it - bony light reflects or maybe bony light reflex. Can anyone help with this. THX
it was light box - light therapy for depression. found it on google. thanks much!
Subject: it was light box - light therapy for depression. found it on google. thanks much!
x
Flucaine and blue light (slit lamp gives a blue light) nm
Subject: Flucaine and blue light (slit lamp gives a blue light) nm
I don't think so. PERL is pupils are equal
Subject: I don't think so. PERL is pupils are equal
and reactive to light. What type of surgery is he referring to??
could he be talking about left and right pupils?
Subject: could he be talking about left and right pupils?
n/m
Normal pupils, s/l skills, disks.
Subject: Normal pupils, s/l skills, disks.
na
Head: Extraocular movements full. Pupils ...
Subject: Head: Extraocular movements full. Pupils ...
phrase is usually normal pupils, visual fields and disks. nm
Subject: phrase is usually normal pupils, visual fields and disks. nm
C-reactive protein
Subject: C-reactive protein
C-reactive protein
Subject: C-reactive protein
xx
RPR came back reactive at 1:16, MHA TP of 4+.
Subject: RPR came back reactive at 1:16, MHA TP of 4+.
It could also be marrow reactive changes.. nm
Subject: It could also be marrow reactive changes.. nm
XX
I know there is a light reflex....not sure about bony light reflex though...nm..
Subject: I know there is a light reflex....not sure about bony light reflex though...nm..
s
He also says nonreactive reactive hepatitis, again, can this be? (nm)
Subject: He also says nonreactive reactive hepatitis, again, can this be? (nm)
probably subchondral medial reactive changes nm
Subject: probably subchondral medial reactive changes nm
xx
Plades ? reactive process
Subject: Plades ? reactive process
MRI showed some mild left neuroforaminal narrowing,plades ? reactive process and some facet hypertrophy. Any guesses?
Maybe C-reactive protein. Used to detect inflammation. nm
Subject: Maybe C-reactive protein. Used to detect inflammation. nm
s
post-strep reactive arthritis
Subject: post-strep reactive arthritis
PSRA (post-streptococcal reactive arthritis) is mentioned at http://www.emedicine.com/PED/topic2006.htm in relationship to rheumatic fever, although "post" doesn't s/l "spin." kj
s/l ____ strep-reactive arthritis? sm
Subject: s/l ____ strep-reactive arthritis? sm
Patient is a 13-year-old male with a
past medical history of rheumatic
fever and ---- strep-reactive
arthritis?
I am not sure about any of it really
after the rheumatic fever to the
reactive arthritis. The blank, I
don't know if it is a stuture or
not, but sounds like "spin". TIA
meds help s/l reactive "siler or silar"
Subject: meds help s/l reactive "siler or silar"
for ankle pain.
try googling - do you hear beta strep-reactive
Subject: try googling - do you hear beta strep-reactive
lots of info out there - good luck!
C-reactive protein is a test for septic arthritis--sm
Subject: C-reactive protein is a test for septic arthritis--sm
particularly in children. could that be it? C-reactive protein is also CRP.
Stedman's GI lists "nonspecific reactive hepatitis." Could this be it? nm
Subject: Stedman's GI lists "nonspecific reactive hepatitis." Could this be it? nm
x
You should dictate what the doc says.
Subject: You should dictate what the doc says.
If he is wrong, that's his problem. You can't just go changing what he says unless you have free reign on your account.
Drs get what they dictate - some of us only do..S/M
Subject: Drs get what they dictate - some of us only do..S/M
brachioplexus, brachioplexopathy - what they say is what they get....client profile RULES!
How does he dictate it? Is he actually - sm
Subject: How does he dictate it? Is he actually - sm
Is he saying "CBC, MSP, and stool" because stool is not a test so just wondering if it could be the name of a stool test. If you state just how the whole sentence is dictated, it may help us figure it out for ya.
I had a doc used to dictate that
Subject: I had a doc used to dictate that
Good says it stands for keep-open-vein. So, it should fit, and it also is all CAPs.
Usually if they dictate Seldinger...
Subject: Usually if they dictate Seldinger...
they will say "via Seldinger, or Seldinger technique." I don't believe they would do this en route either. Are you sure you are hearing "sandwich?" I have been transcribing ER reports for years and I have never heard this term used. Anyway, I would not guess on this one. IMO, it is better to leave it blank and have QA inform you later so you can keep it on file  .
Yes, that was how I was taught and most always they dictate cc nm
Subject: Yes, that was how I was taught and most always they dictate cc nm
nm
welcome; got it from my docs that dictate it as i never could figure them all out either, lol. nm
;
Sorry, but I have had them dictate brain or beta.
Subject: Sorry, but I have had them dictate brain or beta.
nm
Account specifics would dictate whether you sm
Subject: Account specifics would dictate whether you sm
write it out or abbreviate. The abbreviation for beats per minute is bpm. Ask your QA person for approved abbreviations for this account (accounts will differ sometimes which can make us crazy).
Did she dictate the colon after "murmur?" nm
Subject: Did she dictate the colon after "murmur?" nm
x
no matter what they dictate, they are wrong...nm
Subject: no matter what they dictate, they are wrong...nm
LOL..the way these docs dictate anymore
Subject: LOL..the way these docs dictate anymore
who knows!! Something like that just check your aspirin bottle. Good luck!!
doctor didn't dictate mg????
Subject: doctor didn't dictate mg????
The patient was given aminophylline, Lanoxin 0.25, Lasix 40 mg, Cardizem.
okay here the doctor fails to dictate mg? according to 'textbook rules' do I add this or not?
Lordy, when they dictate commas it is just sm
Subject: Lordy, when they dictate commas it is just sm
like a poke in the eye to me!!! Brings me to a screeching halt. I just tend to ignore them, in a report, especially if it is a resident. I do puncturate letters and memos, but half the commas I see people use on this board and other boards are totally not necessary. Just call me
anti-comma!!!!!
If you dictate the full sentence I could probably help you figure it out. nm
Subject: If you dictate the full sentence I could probably help you figure it out. nm
Thanks for finding that. I just had doc today dictate this...hmmmm
Subject: Thanks for finding that. I just had doc today dictate this...hmmmm
doc didn't dictate that....her brain was thinking that...
Subject: doc didn't dictate that....her brain was thinking that...
nm
Thought so thanks wish they would dictate the drugs correctly
Subject: Thought so thanks wish they would dictate the drugs correctly
or may be mistakenly thinking of their pet's food as they dictate?
Subject: or may be mistakenly thinking of their pet's food as they dictate?
wrong - they ALL dictate decubiti...no such word
Subject: wrong - they ALL dictate decubiti...no such word
did he dictate the point, or did he say 1 5, to make sure you did not hear 50
Subject: did he dictate the point, or did he say 1 5, to make sure you did not hear 50
nm
That's what I mean by "ask your QA!" Account specifics dictate style, sm
Subject: That's what I mean by "ask your QA!" Account specifics dictate style, sm
but the AAMT BOS dictates what is correct for the industry, getting its information from sources such as the Chicago Manual of Style, the American Medical Association book of style (which I own), etc. As the poster below states, Joint Commission goes by BOS and does not like "same" or abbreviations for diagnoses, impressions, op titles, etc. They will randomly choose patient charts and go through them to check things like this! It's the Joint Commission which recommends or removes hospital accreditations--a very powerful entity.
So, ask your QA what the account wants. If they want "same," give them "same." For other accounts, do it the correct way.
Derm docs often dictate "Allergy to CARBO mix" - sm
Subject: Derm docs often dictate "Allergy to CARBO mix" - sm
I don't know what the full word is, but this validates your hearing the partial "carbo"
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