That was the whole sentence. It was under the "assessment" part of the note. The patient was
Posted By: lm on 2006-02-16
In Reply to: atypical psycyotic or antipsychotic ) sm - Txczech
Subject: That was the whole sentence. It was under the "assessment" part of the note. The patient was 48. Thanks for your help. Any other ideas??
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
Is there more of the sentence? The 'que' part might be part of a dosage like q.12, etc. nm
Subject: Is there more of the sentence? The 'que' part might be part of a dosage like q.12, etc. nm
s
orthopedic note, see sentence....
Subject: orthopedic note, see sentence....
She has what appears to be a mucous cyst. I do not really see a whole lot of the cyst on today’s exam. She has a little bit of swelling about the joint. There are no signs of any infection. She has a slight extensor lag of the joint, but the joint is stable and she has adequate flexion. There are no signs of any (S/L perinucei)and her x-rays show there is a little bit of arthritic changes in the DIP joint, but there do not appear to be any bony changes.
thanks for any ideas.
Discharge note for patient with MRSA-prescription?
Subject: Discharge note for patient with MRSA-prescription?
Physician says what sounds like: "Tigafil?". He is dictating on phone line from hospital. Poor quality. Please help! Thanks!
Doing cardiac transplant clinic note, patient with SM
Subject: Doing cardiac transplant clinic note, patient with SM
cardiac allograft vasculopathy. Last s/l alamac or LNAPs was 17 on September 5. Last PRAs in July of this year were unremarkable. Note patient has had s/l LNAPs of 34 and 27 TIA
The pt. will be getting a shot of "clindadex" and B12. (of note, the patient has bronchitis)
Subject: The pt. will be getting a shot of "clindadex" and B12. (of note, the patient has bronchitis) Thanks
nk
Sarcoma clinic note - patient found to have coag-neg staph instead
Subject: Sarcoma clinic note - patient found to have coag-neg staph instead
-The plan is to start her on antibiotics as per s/l ID's recommendation and follow her closely.-
This doesn't sound like the name of any of the doctors involved, so I thought it may be a protocol that I'm not familiar with. Thanks for your help!
I wonder if its not part of the sentence before
Subject: I wonder if its not part of the sentence before
x
here is part of the sentence
Subject: here is part of the sentence
Speculum Exam: Large multiparous cervix, creamy white discharge, 1 inch of IUD strings seen from the "poorshoe" of the cervix
here is part of the sentence, thanks....
Subject: here is part of the sentence, thanks....
(the pt is having radiation therapy done) "accessing the epidural port by diconnecting from the ____ fusion (or infusion?)
In what part of the report? Can we have the sentence please? nm
Subject: In what part of the report? Can we have the sentence please? nm
s
Whole sentence please. What part of the body?
Subject: Whole sentence please. What part of the body?
Sentence please or part of body please.
Subject: Sentence please or part of body please.
What is the whole sentence, and what part of body?
Subject: What is the whole sentence, and what part of body?
the patient actually is in for shoulder pain. This is just part of the PE and that's all he says
Subject: the patient actually is in for shoulder pain. This is just part of the PE and that's all he says.
patient's do get "constipation" with chemo, so that could be part
Subject: patient's do get "constipation" with chemo, so that could be part
Could we have the full sentence for the "clock" part
Subject: Could we have the full sentence for the "clock" part
Complete sentence please or what part of body?
Subject: Complete sentence please or what part of body?
What part of the body is this? or give the sentence.
Subject: What part of the body is this? or give the sentence.
Your sentence is part of a neurologic exam. N/M
Subject: Your sentence is part of a neurologic exam. N/M
Unless you have one of the neurologic docs that splits his neuro exam down into separate headings (CRANIAL NERVES, MOTOR, REFLEXES, ETC.), the sentence with orientation and fundi both describe neurologic findings.
Apparently part of patient's history, but not clear...
Subject: Apparently part of patient's history, but not clear...
MRI is reviewed confirming the presence of a full-thickness supraspinatus tendon tear with early glenohumeral arthritis. The patient apparently had a long head biceps tendon operation as well, perhaps s/l an or in acoa.
The patient has another orthopaedic surgeon in New York that has done a shoulder procedure (he says this in the HPI) and I can't tell if he's saying "an" or "in" acoa.
Thanks MT50.
yes! doctor corrected himself and I thought it was part of the sentence. Thanks!
Subject: yes! doctor corrected himself and I thought it was part of the sentence. Thanks!
The "Impression" part of the dictation reflects diagnoses; a patient can have many.
Subject: The "Impression" part of the dictation reflects diagnoses; a patient can have many.
.
In what kind of report? Body part mentioned? The sentence? nm
Subject: In what kind of report? Body part mentioned? The sentence? nm
s
patient had a four part fracture of the greater tuberosity and had a sl/ *semer* prosthesis?? nm
Subject: patient had a four part fracture of the greater tuberosity and had a sl/ *semer* prosthesis?? nm
nm
yeah would not remove any body part with bacitracin. do give us the next sentence please. nm
Subject: yeah would not remove any body part with bacitracin. do give us the next sentence please. nm
.
Please see full sentence re patient here. thanks
Subject: Please see full sentence re patient here. thanks
I did communicate with the patient through a friend of the patient’s whose English was marginal, though clearly better than the patients.
Sentence please, or patient problem?
Subject: Sentence please, or patient problem?
IS your patient named Ruby, or can we have the sentence with this in it? nm
Subject: IS your patient named Ruby, or can we have the sentence with this in it? nm
s
Could you type the sentence out completely? Also what is the patient being seen for?
Subject: Could you type the sentence out completely? Also what is the patient being seen for?
sentence is : The patient has mild anemia, it is greater than 15/8?
Subject: sentence is : The patient has mild anemia, it is greater than 15/8?
has CT changes and a colonoscopy was being done to evaluate for any colon polyps or a neoplasm.
Many drugs sound similar, can u give context of sentence/patient problems? NM
Subject: Many drugs sound similar, can u give context of sentence/patient problems? NM
nm
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
2-part, 3-part, or 4-part possibly - nm
Subject: 2-part, 3-part, or 4-part possibly - nm
noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy
Just wondering if there is any general rule about transcribing noteworthy.
Also, status post; status-post.
Thank you.
doc dictates "the patient has 120 pack year smoking history", patient is 75...is that right???
Subject: doc dictates "the patient has 120 pack year smoking history", patient is 75...is that right???? NM
Patient is here for an s/l eflex injection. Patient previously had Orthovisc.
Subject: Patient is here for an s/l eflex injection. Patient previously had Orthovisc.
nm
Op note ref. SM
Subject: Op note ref. SM
http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note
? pulse ox 99% on room air which is normal per ______ interpretation.
ER note thanks
Subject: ER note thanks
Thanks, practically sure it was per the ER physician reading. So, will be ready for next time!
At the end of OP note, he says
Subject: At the end of OP note, he says
what sounds like "mick" instrument and needle count.
On another, says "sponge, _____and instrument" and that sounds like "lab". Any clues are appreciated. Thank you!
OP note help please sm...
Subject: OP note help please sm...
mild (s/l-fibulations-) with changes on the surface of the condyle
Of note..... I want
Subject: Of note..... I want
to thank everyone so much for all the help I have received on this website since I have become an MT. Bless everyone of you. I hope one day to help those also asking questions as you all have me.
Op note
Subject: Op note
Dictator says: Local Xylocaine 1% anesthesia 'arfate' cannulated.
What is the 'a' word?
me again - same op note :(
Subject: me again - same op note :(
The wound was irrigated and rough edges were S/L RASSED. 
op note help
Subject: op note help
Using an up-biting basket and a S/L 405 shaver a medial meniscectomy was performed.
TIA!
OP NOTE HELP
Subject: OP NOTE HELP
The iliotibial band was then split inline with the incision and retracted anteriorly and posteriorly with a _____ bow. s/l charming.....
The procedure is a cemented bipolar hemiarthroplasty left hip.
OP NOTE STILL
Subject: OP NOTE STILL
Should have went further in the note...sorry...another blank is
Attention was directed to the proximal femur, which was prepared with a box-cutting chisel, _____ canal finder and a trochanteric router this sounds like "chauney"
ESL help with op note
Subject: ESL help with op note
She says: With forceps and a S/L barpotta knife the lesion was excised. (This is excision of a lid nodule). 
have another on this same note - sm
Subject: have another on this same note - sm
Bilateral elbow rheumatoid arthritis. The left side is more advanced with (s/l)'spectus articulusdamage than appears on the right side
op note help
Subject: op note help
This is an excision of a breast nodule. Two questions:
1. The area was prepped with s/l Cloraprep
2. The needle was grasped with an S/L Alice clamp
See note below
Subject: See note below
This is the context of the report. It sounds just like Waddellian. He says this quite a bit and it stumps me every time....
PSYCHIATRIC: The patient was alert and oriented x3 with a somewhat depressed and scattered mood, being very jumpy and quickly agitated by minimal movements or pressures in various areas such as supporting the leg while doing musculoskeletal motor examination for neurologic examination. The patient definitely showed some ____________________ symptoms through our examination. When the idea of psychiatric help in this manner was brought up in this case, the patient seemed almost excited to know this was a coming event.
|
