Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
Posted By: PMH term on 2007-09-22
In Reply to:
Subject: Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
any ideas?
Thanks
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patient with previous cesarean section..sm
Subject: patient with previous cesarean section..sm
preterm premature ruptured membranes, history of cervical prolapse and suspected s/l "cor amniotic" (but her voice trails off at the end so have no idea what she is saying)
Hi - thanks for trying. I was lucky and found a previous report for patient and it is TBSO.
Subject: Hi - thanks for trying. I was lucky and found a previous report for patient and it is TBSO.
nm
Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
Subject: Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
not sure in this case. Account goes by BOS, not super nitpicky, but I'm wondering what y'all do.
What is this, medical term, medication, etc... If med, does patient
Subject: What is this, medical term, medication, etc... If med, does patient
have diabetes?
Patient with vaginal discharge, need help with lab term - sm
Subject: Patient with vaginal discharge, need help with lab term - sm
Patient has vaginal discharge worse after menses. Wet prep has negative yeast, negative trich, negative s/l lith. Is there something that would fit here? Thanks!
not a medical term - the patient is a st____ building inspector
Subject: not a medical term - the patient is a st____ building inspector
The patient is a 43-year-old male st_____ building inspector who presents....
any ideas on what could go before building inspector and start with st? the last syllable of the word sounds like -tial
"Euadrenal is the term used to describe a patient's hormonal status which is grossly normal in
Subject: "Euadrenal is the term used to describe a patient's hormonal status which is grossly normal in the clinical and biochemical sense of global adrenal secretion..."
No previous MI. Tx anyway! nm
Subject: No previous MI. Tx anyway! nm
xx
You might not like this one, but I would go by what QA said on the previous report. This way you hav
Subject: You might not like this one, but I would go by what QA said on the previous report. This way you have verification in writing of why you chose to keep it this way in case you are questioned on your choice of interpretation. I know we are looking for common sense but we are transcriptions and as we know that is not even close to always being the case in MD dictations.
could it be part of previous ??
Subject: could it be part of previous ??
could it be the dosing of the med before and you think he is going to the next number in the list? The "million" part is making me question this. Otherwise I have no idea. I hope you find your answer!
a previous post
Subject: a previous post
had this same sentence and it was "early satiety"
PS to clarify my previous post
Subject: PS to clarify my previous post
2 drugs:
s/l Cadawa NHCTC; I think it's for hypertension or hyperlipidemia.
s/l Rocethrin. For lesions? Could also be a pain med.
TIA! 
I took this from a previous post about eponyms... sm
Subject: I took this from a previous post about eponyms... sm
According to BOS
eponyms
"While the use of the possessive form with eponyms remains acceptible, AAMT's preference is generally to drop the possessive form.
Apgar score, Babinski sign, Down syndrome, Gram stain, Hodgkin lymphoma.
Sometimes an awkward construction calls for use of the possessive form. This patient suffers from Hodgkin's."
just a thought..how about no change to previous?
Subject: just a thought..how about no change to previous?
Previous surgery for s/l lat pulley. TIA nm
Subject: Previous surgery for s/l lat pulley. TIA nm
aaaahh, my previous note should be SM!
Subject: aaaahh, my previous note should be SM!
did the link show up with the previous message?
Subject: did the link show up with the previous message?
Found previous note. It was Sigma...nm
Subject: Found previous note. It was Sigma...nm
nm
Here's a link to a previous MTStars post
Subject: Here's a link to a previous MTStars post
on this same question. Is this an ENT account? The best thing would be see if you can get verification from the account, might be some name they have for their own conconction of Maalox, Benadryl and Xylocaine. I've seen plenty of things misspelled in reports, even standards handed out by an account itself...
no, doesn't make sense....previous does
Subject: no, doesn't make sense....previous does
is this dictator an ESL?
prior history of left shoulder pain?
previous history of left shoulder pain?
Found it in a previous dictation - it is Toronto.
Subject: Found it in a previous dictation - it is Toronto.
OOPS DISREGARD PREVIOUS THIS IS WAY IT IS WRITTEN?
Subject: OOPS DISREGARD PREVIOUS THIS IS WAY IT IS WRITTEN?
A trigger point injection at the right gluteus maximus trigger point was performed using mixture of 2 mL 2% Xylocaine and 1 mL 40 mg per mL Depo-Medrol.
Maybe referring to a stitch from the previous fistula??
Subject: Maybe referring to a stitch from the previous fistula??
x
Agree with previous poster. NEVER GUESS
Subject: Agree with previous poster. NEVER GUESS
x
I was able to locate a previous report which has 1, so I'll go with that
Subject: I was able to locate a previous report which has 1, so I'll go with that
pt with previous respiratory burns on prednisone and now s/l zo air. ?? nm
Subject: pt with previous respiratory burns on prednisone and now s/l zo air. ?? nm
Can you check a sample of doctor's previous
Subject: Can you check a sample of doctor's previous
c
If that's what was said, yes. You'd expand the second one to 42,800 IF your QA allows it. If n
Subject: If that's what was said, yes. You'd expand the second one to 42,800 IF your QA allows it. If not,
s
if CP says to expand, I certainly do expand
Subject: if CP says to expand, I certainly do expand
Expand IV????
Subject: Expand IV????
How would I expand IV? "Plan is to discontinue his IV." When I look it up I get intravenous. That does not sound right......
THANKS!!!
Expand LVH
Subject: Expand LVH
Not sure whether to expand LVH in assessment. It does not appear expanded elsewhere in report. Left ventricular hypertrophy or left ventricular hyperplasia?? Leave as is?
Unless you need to know it to expand it in
Subject: Unless you need to know it to expand it in
the report, I wouldn't waste time over it. If you need to know, ask your supervisor to find out for you.
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Subject: how do you expand L5-S1 in a DS?
How would you expand this sentence in the Diagnosis section of a Discharge Summary.
Do I replace L5-S1 with lumbosacral joint?
My account gives examples that we should expand "Fracture, L2" out to "Fracture, second lumbar" .... so that is why I'm thinking I need to expand the L5-S1...
DIAGNOSES:
1. Right-sided L5-S1 herniated nucleus pulposus.
I never expand
Subject: I never expand
Because abbreviations can mean so many things, I never expand abbreviations even in a diagnosis. Our hospital determined it is the dictators job to edit before signing if they want it expanded.
expand HPI?
Subject: expand HPI?
Forgive my newbiness (that WILL become a word someday, I'm sure of it!) that will clearly be seen in this question!
When the doctor dictates "as stated in the HPI" , should I expand that to History of Present Illness - with those caps in place or only capitalizing the H?
Thanks!
should expand
Subject: should expand
I'm told to expand all those that are not common. (How gloriously vague!) Seems to me that "HPI" is pretty common. But I think I'll go ahead and expand.
So should I capitalize all of it?
I would expand
Subject: I would expand
ANY abbreviations the client wants expanded. Everyone has a preference.
previous s/l attisoning syndrome secondary to steroid use
Subject: previous s/l attisoning syndrome secondary to steroid use
elevated liver functions, previous cholecystectomy.
Subject: elevated liver functions, previous cholecystectomy.
CT showed (S/L) ''normobilia''?? (have looked everywhere and cannot find--thanks for any help.)
capitalization rule after the previous word was a number.
Subject: capitalization rule after the previous word was a number.
how to capitalize the first letter of a new sentence if the last word in the previous sentence was a number?
If you expand it (and you should if your account allows), sm
Subject: If you expand it (and you should if your account allows), sm
it should be "cardiac catheterization," not "cardiac catheter."
only expand it out to metastasis if.....sm
Subject: only expand it out to metastasis if.....sm
Client profile dictates whether or not to give this dictator mets or metastasis.....his saying *met* was wrong. I would've given him *mets* unless the client profile allows expanding of words, and in that case I would've given them *metastasis*
I would expand all as you stated...
Subject: I would expand all as you stated...
I am not on a verbatim account and I do expand those types of abbreviations, but I would be interested in hearing others' opinions as well.
By the way, why are you "dubious"? Just curious!
I wouldn't expand it.
Subject: I wouldn't expand it.
Considering the context in which IV is used, it is its own entity. I would leave it as is.
I think I would just expand this nonsense to have it be
Subject: I think I would just expand this nonsense to have it be
s
I always expand it to saturating. (nm)
Subject: I always expand it to saturating. (nm)
xx
How to expand UBJ obstruction
Subject: How to expand UBJ obstruction
Hi! Need to type UBJ obstruction in an op note. Can't find anywhere in acronyms. Anyone know? Thanks in advance.
Unless you are to expand abbreviations
Subject: Unless you are to expand abbreviations
you transcribe it as dictated.
I always expand everything if CP says so, even lab tests..
Subject: I always expand everything if CP says so, even lab tests..
xx
Unless you have to expand all abbreviations
Subject: Unless you have to expand all abbreviations
don't waste your time worrying about it, just type it.
Expand BMI in op title? sm
Subject: Expand BMI in op title? sm
I couldn't resist putting Guess, since that's what I've had plenty of today. Guess who dictated this report and put in ? maybe the wrong ID? Or is it Dr. ??, or his/her (seriously, I can't tell) PA, or assistant...
Okay, I had to gripe. This is all I get lately. I have actually broken my own record for finding someone who stutters more than someone I used to work for. That's a terrible comparison, as everyone loved thiss doc and doc's dictation.
Thanks..
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