QA ended up changing it to "right" in chief complaint
Posted By: UPDATE on 2006-02-17
In Reply to: What would you do? - hmmm
Subject: QA ended up changing it to "right" in chief complaint
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chief complaint
Subject: chief complaint
H & P~the doctor says chief complaint:?? sounds like a-pen-ded di-ver (crazy, I know)
The patient awakened that morning with right upper quadrant pain, nausea, fever. The patient has colonic cancer? thanks for any help
Chief Complaint
Subject: Chief Complaint
Chief complaint right foot right shin pain. Fell and went to emergency room and had s/l radiax of her ankle,shin, elbow and wrist on the right side. Nothing about her head. :-(
Can you hear Chief Complaint in there? nm
Subject: Can you hear Chief Complaint in there? nm
It's a chief complaint. Just put it in quotes and you're done.
Subject: It's a chief complaint. Just put it in quotes and you're done.
(like you have it)
A little crazy is okay if it's in quotes, LOL.
:oD
No dx? No chief complaint? No planned tx? Give us a clue here! nm
Subject: No dx? No chief complaint? No planned tx? Give us a clue here! nm
s
any more info? Type of exam, chief complaint, anything at all.
Subject: any more info? Type of exam, chief complaint, anything at all.
dd
Chief complaint: s/l Stiler enalrgement with hyperthyroidism. Help???
Subject: Chief complaint: s/l Stiler enalrgement with hyperthyroidism. Help???
what is the name of a third complaint? S/L thirsory complaint Thanks!
Subject: what is the name of a third complaint? S/L thirsory complaint Thanks!
I just wasn't sure if there was a "right" way..
Subject: I just wasn't sure if there was a "right" way..
nm
Does this sound "right" sm
Subject: Does this sound "right" sm
Will check BMP to recheck sodium. I think this was s/l falsely (or could be possibly) low due to her glucose of 280.
Is anyone familiar with this? Is it possible for sodium to be falsely low in the context of high glucose?
Thanks..
Hi, Carol; I am glad you got the "right" help....sm
Subject: Hi, Carol; I am glad you got the "right" help....sm
You know, I have been doing this since 1983, hospital, clinic, in-house, nationals,etc., and I was not trying to say that it was impossible, only that I had not personally heard it, I just thought if you could double-listen, because being an Operative MT especially these last few years, I had PERSONALLY never come across that, even in lower extremity surgery with elderly patients, but I was not saying you were wrong. I am really disappointed, because it seems like some MTs here are treating this board as a personal challenge or contest, who can get the best answer first, and I am the first to know my own limitations, I just share what I PERSONBALLY know. Some (minority) like to criticize other people's answers. If you know better, that is great because you can really help the questioning MT. Why be rude when someone posts and states that they are trying to be helpful? Wow, talk about egos.
maybe "right more than left" edema??
Subject: maybe "right more than left" edema??
could it be "right minor fissure"?
Subject: could it be "right minor fissure"?
s/l "right narrow fissure" on chest x-ray?
Subject: s/l "right narrow fissure" on chest x-ray?
Chest x-ray showed a small amount of fluid in the right s/l "narrow fissure"???
Anyone know of this??
Thanks,
Abby
Well, it is neurology with a chief
Subject: Well, it is neurology with a chief
complaint of unsteadiness of gait. she has a lot of problems, but he says "past medical history: Medical Illnesses: FBS 110. Would you think that would fall under medical illnesses? I'm pretty sure that is what he is saying, though
posted wrong. I mean "right side" isn't close.
Subject: posted wrong. I mean "right side" isn't close.
again, could this be "isolated"???
she is changing her name in threads.....nm
Subject: she is changing her name in threads.....nm
things are changing sm
Subject: things are changing sm
for whose benefit? So the AAMT can profit from more book sales. 15 year MT here--never have and never will buy into AAMT.
Gotten versus changing to got
Subject: Gotten versus changing to got
How many out there think when the doctor says gotten increasing large that replacing got for gotten sure looks better. Does anyone know off hand if there is an official grammar rule here. I think it looks bad!
He may be changing his mind from 4 to 6 as in 24.6 or 24, 600? nm
Subject: He may be changing his mind from 4 to 6 as in 24.6 or 24, 600? nm
.
changing question
Subject: changing question
I guess my original question shoud be if I have 300 cc or more rather than just 1 cc, should it have an s behind it or or just read cc. I have been corrected to be just cc and for some reason I remember it should be apostrophe (cc's)
Changing what is dictated is not always appropriate
Subject: Changing what is dictated is not always appropriate
even if you are offended by profanity. If the doc you are transcribing has a quote in it, you have to type as dictated or it is not a quote. If the physician is using profanity that has nothing to do with what the patient actually said, then some clients require you to change the words, because it is inappropriate otherwise.
My stance on this is just this. If it is a quote, don't change it, because it changes the integrity of the document. Whether you are offended or not, these medical records also serve as legal documents. You must keep that in mind. Just because you are offended is not a reason to change the words.
changing around doctors words
Subject: changing around doctors words
What is considered normal and appropriate.. if the doctor usually says things or an expressoin a certain way and this expression is on my autocorrect is it okay for me to type it in that way (with my autocorrect) if he changes around the sentence but it really means the same thing anyway. Also, how much is it acceptable to change what he says.
It should be mEq. I would feel confident in changing it.
Subject: It should be mEq. I would feel confident in changing it.
x
Medically it would fit, could you give patient's chief complaints and diagnoses? nm
Subject: Medically it would fit, could you give patient's chief complaints and diagnoses? nm
nm
or changing the word "the" to "a" liner...
Subject: or changing the word "the" to "a" liner...
Times they are a changing. Mucopus is a legit word? nm
Subject: Times they are a changing. Mucopus is a legit word? nm
.
what is the patient's condition/complaint? nm
Subject: what is the patient's condition/complaint? nm
can you give more? Diagnosis? Complaint?
Subject: can you give more? Diagnosis? Complaint?
x
maybe "tertiary" complaint (nomsg)
Subject: maybe "tertiary" complaint (nomsg)
x
I type tonic-clonic a lot, and that's not there. So, no one has heard of clinical or changing sm
Subject: I type tonic-clonic a lot, and that's not there. So, no one has heard of clinical or changing sm
Clonic to clonical? Sigh.
That's what I ended up doing. nm
Subject: That's what I ended up doing. nm
nm
thanks. that is what I ended up using. nm
Subject: thanks. that is what I ended up using. nm
nm
Give us the line and context it is used, what is the complaint.
Subject: Give us the line and context it is used, what is the complaint.
Word help s/l glener nerve complaint
Subject: Word help s/l glener nerve complaint
He has not had numbness or tingling in his hands, trouble with walking, s/l glener nerve complaint
Thanks all - I ended up flagging this
Subject: Thanks all - I ended up flagging this
this fellow would call in a 6 minute dictation and then fumble through half of it (literally dead air - so productive), would carry on private conversations with other fellows, rush through the dictations she could do, and then absolutely mangle drug names, etc. Sigh. I think this is Monday not Tuesday.
that is what I ended up sending
Subject: that is what I ended up sending
THANKS!!
Yep - got it - ended up with a 2nd note
Subject: Yep - got it - ended up with a 2nd note
That could be it but I ended up with a blank. Thank you though!
Subject: That could be it but I ended up with a blank. Thank you though!
x
Thank you for your suggestion. I ended up being off on my s/l
Subject: Thank you for your suggestion. I ended up being off on my s/l
Thanks for your help!
I tried to hear that, and it may be what he's saying, but I ended up QA'g
Subject: I tried to hear that, and it may be what he's saying, but I ended up QA'g
That's what I ended up typing. Thanks!!! nm
Subject: That's what I ended up typing. Thanks!!! nm
I ended up having QA take a listen...
Subject: I ended up having QA take a listen...
The first one was "I did not feel it would work well for packing." I missed the "not" which makes sense now. The second one was "Malecot". Thanks for your help!
Thanks IHJB. I ended up figuring it out but I appreciate the help!!! nm
Subject: Thanks IHJB. I ended up figuring it out but I appreciate the help!!! nm
.
I ended up leaving blanks and so did QA so who knows. Thanks though!
Subject: I ended up leaving blanks and so did QA so who knows. Thanks though!
x
Thanks y'all! I just ended up flagging it. He misspells a lot. LOL
Subject: Thanks y'all! I just ended up flagging it. He misspells a lot. LOL
nm
I ended up sending to QA, hope they can figure it out (nm)
Subject: I ended up sending to QA, hope they can figure it out (nm)
Ended up being 'joint tenderness and pain'
Subject: Ended up being 'joint tenderness and pain'
not sure of the test though. I flagged it and hopefully QA will respond and let me know.
it's what I ended up using- just hoping for something better for future reference... (because acc
Subject: it's what I ended up using- just hoping for something better for future reference... (because account specifics say docs don't get to make up words) :)
Can you give us some info about the patient, i.e. past history, current complaint, etc?
Subject: Can you give us some info about the patient, i.e. past history, current complaint, etc?
I ended up putting a blank and a request to find out what it was.
Subject: I ended up putting a blank and a request to find out what it was.
I'll keep you posted:) Thanks for the help!
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