Record Review: S/L
Posted By: bbfof on 2007-03-29
In Reply to:
Subject: Record Review: S/L
'gluteus piriformis intentious fascia lata'
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doc reviewing a record. Any ideas? Available for review is a s/l “fair-row” seven page typewritten
It is Review of Systems and not Review of Symptoms.
Subject: It is Review of Systems and not Review of Symptoms.
No, not a medical record, but it is being put
Subject: No, not a medical record, but it is being put
While I realize it is the OP's responsibility to doublecheck whatever answers received here, and it's fine to be lazy in any other posts on the board, but IMO, it's still a good idea to give correct answers -- spelling, capitalization, and all -- when providing word help. Otherwise, if the OP is also "lazy" it will end up in a medical record the wrong way. Not major in this case, but could be in others ...
Just my opinion, of course.
It's weird because in his record, it's "hypernephrosis" and .....
Subject: It's weird because in his record, it's "hypernephrosis" and .....
I just had to put abdominal pain. 
I think MAR is the Medication Administration Record. nm
Subject: I think MAR is the Medication Administration Record. nm
s
Stands for medication administration record
Subject: Stands for medication administration record
s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
Subject: s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
States: "Review of report in ____ suggests..." Again later in dictation: "Although this is not charted in ____. "
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.
X-Ray Review help
Subject: X-Ray Review help
X-RAYS: Review of her x-rays today show that she has a three-part fracture of her proximal humerus with head rotated and the (something ending with) 'osity' displaced. 
Thanks
Thats all in Review of systems.
Subject: Thats all in Review of systems.
Thanks though!
Under review of systems...
Subject: Under review of systems...
Sounds like dictator is saying:
Abdomen: Soft. Flat. Obese. Pressure: Soft. Obese. No point of splenomegaly was noted.
However, it doesn't seem to me that this would fit. He may be saying another heading instead of pressure but it is too jumbled to tell. 
Also this may be: No signs of [something] or splenomegally is noted.
Thanks in advance!
Review of Systems
On Review of Systems, he's saying . . ."@#$#&*&(" : No recent skin rash. and then something else "@#$#$" : No anemia or lymph gland problems. Psychiatric - No recent depression. Can anyone tell me what these headings could possibly be? I can't even get enough to give you a "sounds like".
In Review of Systems
Subject: In Review of Systems
There is no history of diabetes, polyuria, polydipsia, seizure, stroke, TIA, loss of strength or sensation, or DVT s/l pulmonary mesin around level bleeding.
It might be 'pulmonary embolism' but I might just be wanting to hear that, it's kind of a stretch. But the rest...
Any ideas??? Thanks.
Review of systems
Subject: Review of systems
Review of systems include shortness of breath and s/l ricacaria?? Anyone ...help???
Q in Review of Systems
Subject: Q in Review of Systems
When the doc says - Rest of systems: Negative. do we write it that way or list the systems with Negative next to them all?
Doc doing review. Any ideas? sm
Subject: Doc doing review. Any ideas? sm
Available for review is a s/l “fair-row” seven page typewritten report.
Do you want to know was ROS is? Review of systems.
Subject: Do you want to know was ROS is? Review of systems.
review of systems twice
Subject: review of systems twice
The doc says his normal ROS. At the end of his thought he pauses for a LONG TIME and then says "ROS, on the line, otherwise negative."
So should I do it like I have below or what are your suggestions?
REVIEW OF SYSTEMS: blah blah blah.
A review of systems is otherwise negative.
In review of systems he says,
Subject: In review of systems he says,
"no fevers, chills or sweat s/l size-or-trizer?
Review of Systems
Subject: Review of Systems
Of course...You are correct. I was typing too fast. :-)
Review of Systems
Subject: Review of Systems
I knew that is what you meant.
It is indeed "is"....as review is single.
Subject: It is indeed "is"....as review is single.
 Boy, if that don't make sense, nuthin' does! I fried my brain years ago though...a product called White-Out...hey, it was the 80's and what else was there to do in typin' class?
possibly - I am sending for review
Subject: possibly - I am sending for review
Ever heard of this? Xray review
Subject: Ever heard of this? Xray review
Review of his x-rays today show no evidence of any s/l 'ab-lateral compartmental arthritis.
wasn't sure if this was an actual word (short for something) or if he possibly tumbled over his words and just meant to say lateral compartmental . . .
thanks for the help.
Disregard - I marked for QA to review.
Subject: Disregard - I marked for QA to review.
Disregard - I am sending for review
Subject: Disregard - I am sending for review
Not saying ROS of review of systems is negative? nm
Subject: Not saying ROS of review of systems is negative? nm
s/l taw-tur-tile CRP. Lipid lab review.
Subject: s/l taw-tur-tile CRP. Lipid lab review.
 One of those days when I can't understand anyone!
Other review of systems showed s/l OS negative
Subject: Other review of systems showed s/l OS negative
Other "review of systems" ____ showed s/l "OS" negative.
Review of systems: See HPI (History of Present Illness.)
Subject: Review of systems: See HPI (History of Present Illness.)
Good post for newbies and a review for us oldies who have sm
Subject: Good post for newbies and a review for us oldies who have sm
been transcribing these studies since they were first initiated years ago.
review of systems is "pan positive" with a lot of problems. Is this right? nm
Subject: review of systems is "pan positive" with a lot of problems. Is this right? nm
Is this right "A "ten part" review of systems reveal?
Subject: Is this right "A "ten part" review of systems reveal?
n/t
"Female: Negative" under a male's Review of Systems?
Subject: "Female: Negative" under a male's Review of Systems?
This is the only doc i have ever seen do this... can someone explain? I'm confused.
Psychiatry. Pt with depression and positive s/l "Siggy Capps" review. nm TIA.
Subject: Psychiatry. Pt with depression and positive s/l "Siggy Capps" review. nm TIA.
nm
Review of systems: Chills, night sweats,*commerfid*
Subject: Review of systems: Chills, night sweats,*commerfid*
TIA!
Thanks everyone. I ended up going with edematous paretic, but flagged for review just in case...
Subject: Thanks everyone. I ended up going with edematous paretic, but flagged for review just in case...
nm
14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?
Subject: 14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?
n/t
Pt with migraines with aura, in review of systems, episodic visual s/l C D O's. nm
Subject: Pt with migraines with aura, in review of systems, episodic visual s/l C D O's. nm
Review of MRI shows some mild edema within the pubic s/l syn-th-o-ceel region.
Subject: Review of MRI shows some mild edema within the pubic s/l syn-th-o-ceel region.
Thanks so much!!!
Review of x-rays show a s/l web-a-ray nondisplaced fracture of the lateral malleolus.
Subject: Review of x-rays show a s/l web-a-ray nondisplaced fracture of the lateral malleolus.
TIA :-)
?break in dictation for MT instruction? i see "add this to review of systems above the extremity
Subject: ?break in dictation for MT instruction? i see "add this to review of systems above the extremity section" in your s/l ?? nm ??
In Review of systems: Hem/Lymph: Has long-term bruising, no s/l atreemia, noncontributory. nm
Subject: In Review of systems: Hem/Lymph: Has long-term bruising, no s/l atreemia, noncontributory. nm
I know, but on head and neck exam in review of systems, it is very usual for Dr. to make mention of
Subject: I know, but on head and neck exam in review of systems, it is very usual for Dr. to make mention of ,,,,
all the usual complaints of the specific region, as in neck, no lyphadenopathy, chest, no rales or wheezes, etc., it is a consult. What does he say about something green on the guy's head????
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