Under what heading would you SM
Posted By: tiff on 2008-02-14
In Reply to:
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
TIA
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how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
Thanks.
EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
EKG: EKG today show no ST wave changes.
Heading?
Subject: Heading?
This is for a psych. consult. After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.
I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records. Past Medical History, yes, but not the other. Any ideas?
Oops, used same heading, need help
Subject: Oops, used same heading, need help
Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".
Thanks
IV abbreviated in heading
Subject: IV abbreviated in heading
Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?
under abdomen heading
Subject: under abdomen heading
s/l "the PICC was created" or "the tic was created"
Angie
Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?
I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with
s
I think doc left heading out sm
Subject: I think doc left heading out sm
He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.
What would be asymmetrical here?
I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm
One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
A lot of facilities use the heading
Subject: A lot of facilities use the heading
"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?
Just wondering under what physical exam heading other MTs put this finding under.
TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.
I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they
want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?
I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
Sorry, this should have been under heading Physical Examination.
Subject: Sorry, this should have been under heading Physical Examination.
In my opinion, should be spelled out in heading
Subject: In my opinion, should be spelled out in heading
nm
Not the OP, but a skin prep would be under a different heading
Subject: Not the OP, but a skin prep would be under a different heading
s
Heading in exam? COR: Cardiac etc.
Subject: Heading in exam? COR: Cardiac etc.
Make INFORMANT a new heading.
Subject: Make INFORMANT a new heading.
CHIEF COMPLAINT:
Lump on the side of the neck.
INFORMANT:
Mother and patient.
i would say Examination and Evaluation needs to be put as a heading.
Subject: i would say Examination and Evaluation needs to be put as a heading.
just my thoughts.
I use IMAGING as the heading for EKG, CAT scans, etc.
Subject: I use IMAGING as the heading for EKG, CAT scans, etc.
Hi, Julia, capitalize when used as heading, otherwise, SM
Subject: Hi, Julia, capitalize when used as heading, otherwise, SM
it is part of the sentence and should not be capizalized, somewhat like saying that patient is coming in for a complete physical exam, would not need to capitalize.
Not saying COR as a heading? for heart exam etc? nm
Subject: Not saying COR as a heading? for heart exam etc? nm
H&P exam heading questions
Subject: H&P exam heading questions
doctor is dictating in paragraph form on the PHYSICAL EXAMINATION part sometime subheadings are givenhere it is: His vital signs his pulse is 112, his respirations are 14, his blood pressure is 157/86. His general appearance is he appears quite comfortable, his face is flushed. Non-toxic and no respiratory distress. His neck is supple, he demonstrates full motion of his neck without pain s/l orshe finds tenderness to palpatation. I believe this should be typed this way: VITAL SIGNS: Pulse is 112, respirations are 14, blood pressure is 157/86. GENERAL APPEARANCE: He appears quite uncomfortable, his face is flushed. Non-toxic and no respiratory distress. NECK: His neck is supple, he demonstrates full range motion of his neck without pain Or she finds tenderness to palpation. I would ask my instructors about these, it seems like every time I get graded each assignment it different.
Dee tra emphasis? heading under neurologic..
Subject: Dee tra emphasis? heading under neurologic..
Under physical exam, neurologic, this is given as a subheading....
s/l dee tra emphasis:
sounds like should be under "neurologic" heading
Subject: sounds like should be under "neurologic" heading
Not a typical heading, but how about "question etiology." nm
Subject: Not a typical heading, but how about "question etiology." nm
x
brain freeze..in ROS: what heading would polyphagia go under? thank u
Subject: brain freeze..in ROS: what heading would polyphagia go under? thank u
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.
does she want you to put in a heading, or include more in prior paragraph
Subject: does she want you to put in a heading, or include more in prior paragraph
nm
Culture and sensitivity would be right like you have it. You don't need to make a heading for it
Subject: Culture and sensitivity would be right like you have it. You don't need to make a heading for it.
COR is an acceptable heading for Heart/Cardiovascular.
Subject: COR is an acceptable heading for Heart/Cardiovascular.
x
H&P heading help again.. Past Medical History
Subject: H&P heading help again.. Past Medical History
dictator says: Past medical history for hypertension. Past surgical history is arthroscopy of his right knee. Allergies are to Demerol and Penicillin. Do I put Headings over each one and keep the exact dictation like this: PAST MEDICAL HISTORY (type under this title) Past medical history for hypertension OR just Hypertension. Other part of my question. ROS subheadings: dictator says this: Cardiovascular has a history of hypertension. do I need to put a colon in there and cap the Has? or leave as I have typed in bold? Do I add a subheading of GI/GU: for this sentence - No GI/GU problems. Does this sentence also need colon? Musculoskeletal I stated in the HPI. No neurological or hematological discorders. Thanks for any help, sorry if these seem like dumb questions...but I really need the help.
I would make dg meds a heading, then type Patient is still... under it. nm
Subject: I would make dg meds a heading, then type Patient is still... under it. nm
x
capitalization question - if refers to a heading in the note, do I cap
Subject: capitalization question - if refers to a heading in the note, do I cap
In the dictation, MD says (in ROS) "...please see history of present illness." Do I type "...please see History of Present Ilness" or no caps?
Okay. I was just checking. Lilly would be right. Sclerae and put under HEENT heading.
Subject: Okay. I was just checking. Lilly would be right. Sclerae and put under HEENT heading.
If it is used in heading, as in Diagnosis: XXX, then yes, but if just in body of report in sentence,
Subject: If it is used in heading, as in Diagnosis: XXX, then yes, but if just in body of report in sentence, ...sm
you can abbreviate, depending on acount specifics and what your company or doctor wishes. Hope this helps!
Could it be a heading under PE? ex: Urinary: Urine obtained from cath...
Subject: Could it be a heading under PE? ex: Urinary: Urine obtained from cath...
Yes, as the first word of a sentence or leading heading, you would capitalize. .. see message
Subject: Yes, as the first word of a sentence or leading heading, you would capitalize. .. see message
The following is taken from the Centers for Disease Control website also... note in the middle of the sentence, gray is not capitalized. :)
Primer on Radiation Measurement
In the aftermath of a radiological emergency the public will see radiation and its potential hazards described in many different and sometimes confusing ways. This primer is intended to help journalists and community leaders understand these terms.
Activity or radioactivity is measured by the number of atoms disintegrating per unit time. A becquerel is 1 disintegration per second. A curie is 37 billion disintegrations per second, which is the number of disintegrations per second in 1 gram of pure radium. A disintegrating atom can emit a beta particle, an alpha particle, a gamma ray, or some combination of all these, so becquerels or curies alone do not provide enough information to assess the risk to a person from a radioactive source.
Disintegrating atoms emit different forms of radiation–—alpha particles, beta particles, gamma rays, or x-rays. As radiation moves through the body, it dislodges electrons from atoms, disrupting molecules. Each time this happens, the radiation loses some energy until it escapes from the body or disappears. The energy deposited indicates the number of molecules disrupted. The energy the radiation deposits in tissue is called the dose, or more correctly, the absorbed dose. The units of measure for absorbed dose are the gray (1 joule per kilogram of tissue) or the rad (1/100 of a gray). The cumulative dose is the total absorbed dose or energy deposited by the body or a region of the body from repeated or prolonged exposures.
Alpha particles, beta particles, gamma rays, and x-rays affect tissue in different ways. Alpha particles disrupt more molecules in a shorter distance than gamma rays. A measure of the biologic risk of the energy deposited is the dose equivalent. The units of dose equivalent are sieverts or rem. Dose equivalent is calculated by multiplying the absorbed dose by a quality factor.
Sometimes a large number of people have been exposed to a source of ionizing radiation. To assess the potential health effects, scientists often multiply the exposure per person by the number of persons and call this the collective dose. Collective dose is expressed as “person-rem” or “person-sieverts.”
Is there such a thing as s/l Preda insulin? <- under heading of current medications
Subject: Is there such a thing as s/l Preda insulin? <- under heading of current medications
Where I work, we have a heading called "Diagnostic Tests". This covers everything. nm
Subject: Where I work, we have a heading called "Diagnostic Tests". This covers everything. nm
nm
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