The "Impression" part of the dictation reflects diagnoses; a patient can have many.
Posted By: giddy pc guru on 2007-02-02
In Reply to: follow up Q - yuneci
Subject: The "Impression" part of the dictation reflects diagnoses; a patient can have many.
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- IMPRESSION prob - yuneci
- follow up Q - yuneci
- The "Impression" part of the dictation reflects diagnoses; a patient can have many. - giddy pc guru
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I need an opinion on the best medical dictation to put on my computer. I am starting a part-time
Subject: I need an opinion on the best medical dictation to put on my computer. I am starting a part-time
job and need to order one--suggestions/comments??????
Any diagnoses for the patient? nm
Subject: Any diagnoses for the patient? nm
s
Any diagnoses on this patient? nm
Subject: Any diagnoses on this patient? nm
s
can you give the patient's diagnoses?
Subject: can you give the patient's diagnoses?
Dictation on a patient who is to
Subject: Dictation on a patient who is to
Under recommendations, doc says...number one...s/l ty pen hole or hold. What is the 't' word.
Does the dictation indicate if the patient also has
Subject: Does the dictation indicate if the patient also has
a diagnosis of PCOS?
Is this patient presurgery for anything? Where in dictation is this said? nm
Subject: Is this patient presurgery for anything? Where in dictation is this said? nm
s
Is this the same patient's dictation from earlier this morning?
Subject: Is this the same patient's dictation from earlier this morning?
Any mention of the patient's diagnosis in the dictation? It could be..
Subject: Any mention of the patient's diagnosis in the dictation? It could be..
Avonex which is prescribed for the treatment of multiple sclerosis.
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
Reflects/reflex.
The drum is blunt, poor light reflects/reflex. Which is correct? TIA.
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
Oops! Meant "IMPRESSION" is correct. Brain dead after typing all night.
Subject: Oops! Meant "IMPRESSION" is correct. Brain dead after typing all night.
That was the whole sentence. It was under the "assessment" part of the note. The patient was
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??
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.
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
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
2-part, 3-part, or 4-part possibly - nm
Subject: 2-part, 3-part, or 4-part possibly - nm
I think it is only the diagnoses that need....
Subject: I think it is only the diagnoses that need....
to be spelled out. This part is more like the plan.
diagnoses
Subject: diagnoses
Axis I - VI are not arms of one diagnosis, but of many diagnoses, in different systems and considerations. They include psychiatric diagnoses, functional diagnoses, physical illness diagnoses, etc., etc.
Diagnoses...
Subject: Diagnoses...
Croup and bronchitis.
Procedures: nasogastric tube feed and OPM study. Also says that OPM study indicated silent aspiration.
Any other diagnoses?
Subject: Any other diagnoses?
diagnoses
Subject: diagnoses
Debility.
Dementia with acute confusional state.
Abrasion to shoulder.
Metastatic disease.
Dehydration.
End-stage COPD.
Arthritis.
SIADH.
Hypokalemia.
Hyponatremia.
Bowel obstruction, etiology undetermined.
Urinary tract infection.
Septic condition of blood.
diagnoses
Subject: diagnoses
Diagnoses as follows:
paroxysmal atrial fibrillation, end-stage renal disease, Lown-Ganong-Levine syndrome, hypertension, hypopituitarism, acromegaly, hyperparathyroidism, hypothyroidism, insulinoma.
does that help?
Diagnoses....
Subject: Diagnoses....
Hypertension, chronic edema, hypothyroidism, pacemaker placement, mitral valve prolapse, DVT, hyperlipidemia, GERD, proteinuria, right-sided heart failure
No, see diagnoses. Thanks.
Subject: No, see diagnoses. Thanks.
1. Acute left chest pain.
2. Esophagitis.
3. Coronary artery disease.
4. Hypertension, severe.
5. Probable renal artery stenosis.
6. Peripheral vascular disease.
7. AKI.
8. Malnutrition.
9. Anemia.
Two diagnoses nm
Subject: Two diagnoses nm
k
are these diagnoses...
Subject: are these diagnoses...
correct? He rambles them all together, not sure if I am correct with what I am hearing.
DIAGNOSES:
1. HARDWARE PAIN, RIGHT SECOND METATARSAL FUSION WITH A HISTORY OF DEEP INFECTION AFTER HAMMERTOE PROCEDURE, RIGHT SECOND TOE
2. PAIN AFTER KNEE REPLACEMENT
3. PAIN, LEFT FOOT
tia.
is this 2 or 3 diagnoses?
Subject: is this 2 or 3 diagnoses?
DIAGNOSES:
1. LEFT KNEE LATERAL MENISCUS TEAR
2. OSTEOCHONDRAL DEFECT
3. RIGHT KNEE DEGENERATIVE JOINT DISEASE
Not sure if Right knee degenerative joint disease should be number 3. tia.
I should have put the diagnoses which are..
Subject: I should have put the diagnoses which are..
1. GOUTY ARTHROPATHY
2. NEURALGIA PAIN
3. FAT PAD ATROPHY
Would it still be hallux shoes and also if so would Hallux be capitalized? Thanks for your help.
on diagnoses -diseases
Subject: on diagnoses -diseases
DISCHARGE DIAGNOSES
- Relapse acute myelomonocytic<soundslike> leukemia.
- Severe pancytopenia due to bone marrow hypopasia secondary to cancer chemotherapy.
- Sepsis, possibly due to staphylococcus lubdenensis.
- Ogroshong<soundslike> catheter exit site infection.
- Hypocholemia.
Doc says in diagnoses list...
Subject: Doc says in diagnoses list...
Status post PCIA with stents in the left anterior descending.
Can't find PCIA. Did find PCI - percutaneous coronary intervention. Or does he mean PTCA?
Are they receiving TPN? Or do you have any diagnoses? nm
Subject: Are they receiving TPN? Or do you have any diagnoses? nm
s
Yes, it's discharge diagnoses-First
Subject: Yes, it's discharge diagnoses-First
one is enterobacter septicemia due to line infection.
could definitely fit in with diagnoses and problems
Subject: could definitely fit in with diagnoses and problems
Thanks so much!
Have a great day!
any diagnoses or dosage?
Subject: any diagnoses or dosage?
one diagnosis or more diagnoses
Subject: one diagnosis or more diagnoses
DIAGNOSIS: INTERNAL DERANGEMENT, RIGHT KNEE
TEAR OF THE LATERAL MENISCUS, RULE OUT MEDIAL MENISCUS TEAR
EARLY DEGENERATIVE ARTHRITIS
Not sure if this is all one diagnosis or more. Any ideas. The only thing that I think makes it sound to be one is because he doesn't mention which knee for any of the others. If it is one how would you punctuate. Sorry for so many questions but I am confused..tia.
Final Diagnoses
Subject: Final Diagnoses
1. Congestive heart failure.
2. Cellulitis, right leg.
3. Cardiomyopathy.
4. Morbid obesity.
Do you know the diagnosis or diagnoses?
Subject: Do you know the diagnosis or diagnoses?
Normally, you don't number diagnoses
Subject: Normally, you don't number diagnoses
within an axis. We do this.
Axis I: xxxxx
xxxxxx
Axis II: xxxxx
etc. Each diagnosis is on a separate line, but not numbered.
The SSA was given in a list of diagnoses. sm
Subject: The SSA was given in a list of diagnoses. sm
Totally occluded bilateral SSA stenosis. Patent s/l "profundal" arteries.
Also in list is of diagnoses is the following....Coronary artery bypass graft and "SVG to LAD", "SVG to OM"... not sure on these abbreviations... can you tell I am completely lost....
It's a list of discharge diagnoses...
Subject: It's a list of discharge diagnoses...
DKA, then s/l Right leg varicose, then obesity. He says it later in the report and it definitely s/l varicose.
listed in diagnoses, no sentence
Subject: listed in diagnoses, no sentence
.
Was that a typo? I've never had VI diagnoses, only 5.nm
Subject: Was that a typo? I've never had VI diagnoses, only 5.nm
I believe the are 2 separate diagnoses and would transcribe as such.
Subject: I believe the are 2 separate diagnoses and would transcribe as such.
.
whats the diagnoses?---this ending could be a lot of
Subject: whats the diagnoses?---this ending could be a lot of
diff meds, first one that comes to my mind is
fluoxetine
Can you look in the pt's diagnoses for clues? Think your PT/INR phrase
Subject: Can you look in the pt's diagnoses for clues? Think your PT/INR phrase
s
context, sentence? - diagnoses?....nm
Subject: context, sentence? - diagnoses?....nm
Any past history or diagnoses? nm
Subject: Any past history or diagnoses? nm
s
any diagnoses or problem list?
Subject: any diagnoses or problem list?
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