Rules for tense in a report?
Posted By: any QA rule for this? on 2007-05-04
In Reply to:
I always thought it was past tense. I have a doc who started the first 2 sentences using past tense and then suddenly switched to present test. IV sedation IS administered, Patient IS positioned. Do you change present to past or type as is? Nothing in the CP about it.
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I think it a doctor tense of tenodesis and have been typing that tense "tenodese" for years (s
Subject: I think it a doctor tense of tenodesis and have been typing that tense "tenodese" for years (sm)
There is an article from the Journal of the American Society for Surgery of the Hand that spells it that way too http://linkinghub.elsevier.com/retrieve/pii/S1531091404000981 -
past tense or present tense.sm.
in PE. Doctors love to toggle back and forth between is, are, and was, and were! On ASR we are told not to over edit! What would you do.... anybody :)
probably tense.............
Subject: probably tense.............
x
s/l ice on tense?
Subject: s/l ice on tense?
fossa fluid collections surrounding the cerebellar hemispheres, which are also (ice on tense) to CSF
She lay in bed, present tense....sm
Subject: She lay in bed, present tense....sm
she laid in bed all day Saturday (past tense).........
past tense of I & D (I & D'd?)
Subject: past tense of I & D (I & D'd?)
doc says ...four years ago. It was I & D'd at that time.
how about "a tense effusion"
Subject: how about "a tense effusion"
tense effusion
Subject: tense effusion
Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau
(www.aafp.org/afp/20030901/907.html)
since he "laid" down -- past tense (sm)
Subject: since he "laid" down -- past tense (sm)
lay is usually for inanimate objects
lie would be present tense
if its past tense... it would be laid
Subject: if its past tense... it would be laid
/
it is laid if it is past tense
Subject: it is laid if it is past tense
on all reps I try for present tense except
Subject: on all reps I try for present tense except
Biceps tense up well when he exerts
Subject: Biceps tense up well when he exerts
Does this make sense? Here is the previous sentence.
Tenderness over the anterior shoulder at the site of biceps insertion. Biceps tense up well when he exerts.
Regarding AAMT rules
Subject: Regarding AAMT rules
I go with my client preference, and when I began working his account, the sample reports did not use BOS rules. I only use numerals to express drug dosage, measurements, dates, etc. I also agree with you on the appearance of it.
number rules?
Subject: number rules?
Two of my teachers taught different number rules. One, said that they should almost always be numeral form. The other said that numbers are usually spelled out.
I believe the Book of Style says numerals are usually appropriate, accept for zero, at the beginning of a sentence, drug admin. abrev's., etc..
Anyone? Numerals right? With acceptions? I'm just starting.
I do agree with you, but it seems none of the rules fit this..
Subject: I do agree with you, but it seems none of the rules fit this..
BOS says if you can put "and" between the adjectives then use a comma, which in this case you really can't until btwn telangiectatic and vascular. Just always second guessing myself.
Thank you!!!!
IF you are to follow BOS rules...sm
Subject: IF you are to follow BOS rules...sm
The patient has Alzheimer disease.
She has Alzheimer's.
Don't use the apostrophe S when 'disease' follows.
But, that is the BOS rule. Your client and/or company may prefer it's own rule.
Format rules in MT
Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home. Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way. Problem #1 - HYPERTENSION. The patient is taking lisinopril currently..... or if the doc did not say PROBLEM #1, then you transcribed it 1. HYPERTENSION. Blah, blah, blah. When did this change and become wrong? Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem. Is this in the so-called AHDI BOS2?
IMHO, using the capitalization on the problem is much easier to read, than this...
1. Hypertension. The blah, blah, blah..
2. Diabetes mellitus type 2. Uncontrolled. Not compliant.
Any QAers out there can answer this one for this old school nitpicker?
You are absolutely correct. It is lay...past tense has nothing to do with it in this case!
Subject: You are absolutely correct. It is lay...past tense has nothing to do with it in this case!
/
Well, CLIENT PREFERENCE rules.....sm
Subject: Well, CLIENT PREFERENCE rules.....sm
Always, always it's client preference. I was just speaking in a BOS/AAMT ruling about numbers. Client preference most definitely IS the bottom line.
Help, I can't remember the hyphen rules.
Is there a hyphen with non-radiating and non-icteric, or all one word, or separated? Thanks. I'm an old dog and I don't want to learn new tricks.
Rules here per admin is No Testing..sm
Subject: Rules here per admin is No Testing..sm
hope you have a happy happy new year and good luck in your studies/testing
thanks....lots of rules with numbers!
Subject: thanks....lots of rules with numbers!
Rules change over the years
Subject: Rules change over the years
but some rules are that way just because it sounds right. 5 centimeters were injected just sounds ignorant and I don't care who you are, as Larry the Cable Guy would say. ;-)
I would say the dictator made up his/her own tense to the word bursitis, would flag it and have QA l
Subject: I would say the dictator made up his/her own tense to the word bursitis, would flag it and have QA let you know.
to the best of my knowledge it is a word (past/versus present tense)
Subject: to the best of my knowledge it is a word (past/versus present tense)
If your account doesn't have specific rules about it, sm
the correct way would be to write it out in full (Escherichia coli) whether or not it was dictated in full. Then, if the dictator says E. coli after that, then it is correct to transcribe it that way. If the dictator says it in full the next time, then transcribe it in full. Check your account's guidelines for their preference.
ALS is correct per AAMT rules. See cite.
I don't care whether the BOS is right or wrong on the issue. I have to use it and so do others. Here's what it says.
As per AAMT BOS 2nd edition page 189: Always capitalize genus names and their abbreviated forms when accompanied by species name. Lowercase genus names used in plural and adjectival forms and when used in the vernacular; for example, when they stand alone without a species name.
as poster above stated, I was going with BOS rules...relax! :) nm
Subject: as poster above stated, I was going with BOS rules...relax! :) nm
I think just the normal rules of English would apply
Subject: I think just the normal rules of English would apply
Whenever adding *ing* to a word that ends in t, you add an extra t.
A couple of grammar rules are at play here
Subject: A couple of grammar rules are at play here
First of all, both got and gotten are correct forms of the verb get. However, got is a past tense or past participle depending on whether or not the word "has" or "have" is used in front of it. Gotten, however, is past participle and should be used with the word "has" or "have" in front of it.
It has gotten increasingly larger - okay. It gotten increasingly larger - not okay. It got increasingly larger - okay. It has got increasingly larger - okay.
So if your doc says it anyway but "It gotten increasingly larger", he is correct. It's simply a matter of preference. Brits don't generally use the word "gotten", and therefore, a lot of people think it is not a legitimate word, but it is.
Time format rules in BOS 3rd edition?
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever is easier.
I do intend to buy my own soon but I have to wait till payday and I'm starting a new company right now that uses that book :(
TIA !
Ringer. AAMT BOS2 rules on eponyms.
Subject: Ringer. AAMT BOS2 rules on eponyms.
I believe that is only if the company is compliant with JCHO rules. Not all companies are.
Subject: I believe that is only if the company is compliant with JCHO rules. Not all companies are.
By AAMT rules, need help with period with drug values. (sm)
Subject: By AAMT rules, need help with period with drug values. (sm)
Is this right?
1 gm
0.1 mg
1 mg
I was taught that it was 1.0 mg but doc wants it to be just 1 mg and 1 gm.
Help. Thanks.
It is not 'erroneous', only add to the AAMT rules, which change every year!
Subject: It is not 'erroneous', only add to the AAMT rules, which change every year!
To say that the plural form decubiti for the singular of decubitus is
'erroneous' is plain BS !
And it is known that the AAMT, now it has another name, 'makes up' its own grammar rules for the MTing.
This issue has been discussed numerous times on this board and causes a lot of confusion for the MTs and arguments between MTs, QAs and the clients.
EVERY year the BOS rules are changed. We just got used to the BOS 2 and in December 08 the BOS 3 was issued, again with new rules to adhere. The price is around $ 90.--.
EKG report
Subject: EKG report
"No weeshnoblomotion abnormalities are identified." What is that word?
thanks everyone. One more report and then I am going to bed.
Subject: thanks everyone. One more report and then I am going to bed.
nothing more to add about the report unless
Subject: nothing more to add about the report unless
the patient had an implanted pacemaker which is not eluded to here. Just a note, adenosine is not capitalized except to start a sentence.
Maybe you will hear something back.
d~
Sorry, same report...
Subject: Sorry, same report...
"CPK and _______ were negative" s/l intraconals??
Still on the pulmonologist's report...
EEG report
Subject: EEG report
Anyone ever heard of an EEG performed on a Nikon Codon machine? Thanks.
just sent the report on.........nm
Subject: just sent the report on.........nm
x
op report sm
Subject: op report sm
What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.
You don't say where in the report -- sm
Subject: You don't say where in the report -- sm
this is given, or any other context, so I have to wonder if this isn't a problem list perhaps giving more than one diagnosis/problem here (as in (1) portosystemic shunt and (2) nephrolithiasis)...
Just a thought
ENT report - sm
Subject: ENT report - sm
Does include sinus surgeries, Caldwel-Luc surgery. Is also on Flonase. Patient is actually here regarding Grave's disease. I'm wondering if this is Relpax D, but I'm not able to verify that as a drug. Any suggestions?
ENT OP report help, please...
Subject: ENT OP report help, please...
Vocal cord lesion biopsy -
Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.
Specimen was sent -s/l informal- and for pathology.
TIA!
OP report
Subject: OP report
OP report, lumbar spine
Next, fluoroscopy was used to place new screws at the L2-3 segment. Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis
He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!
op report help please sm...
Subject: op report help please sm...
FINDINGS: Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle. The patient did experience some concordant L5 symptoms on the right side during the injection. Vital signs remained stable throughout.
OP Report
Subject: OP Report
Hi all! I am doing an OP for a lumbar spine surgeon, but this is just for an I&D. He says the area was probed with "sucker tips" and was found to be subfascial. I am not too comfortable with what I am finding online for this. Has anyone heard this before? Thanks!
OP report help, please
Subject: OP report help, please
Patient was premedicated with intravenous s/l Benadryl.
Would that be right?
report does not say .. but says she is on BC
Subject: report does not say .. but says she is on BC
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