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Usually depends on the type of report

Posted By: AnnuderMT on 2009-05-28
In Reply to: yes! - grace

Subject: Usually depends on the type of report

While account specifics vary from hospital to hospital, I don't think I've had a hospital with an H&P that didn't require that you separate out the headings; discharge summaries, on the other hand, are usually allowed to be in paragraph form, and consults are a toss-up. Clinic/office notes are totally a matter of account specifics. When you get into specialty clinics, they sometimes break it down even further; i.e., an ENT doctor may separate out HEAD: EYES: EARS:, etc., and a neurologist may do MENTAL STATUS: CRANIAL NERVES: STRENGTH: REFLEXES, etc. However, in most cases, if the doctor uses headings in an exam for some of the systems/body parts, you usually are to use the appropriate ones for all; as noted, though, that is dependent on account specifics.


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Depends on the type of letter
Subject: Depends on the type of letter

If it is business correspondence, I would use the person's "official" first name. If it is a personal letter, I would use the nickname.


If you're not sure, I would advise leaving it blank.


JMHO


I type CT head all the time but I guess it depends sm
Subject: I type CT head all the time but I guess it depends sm

on the sentence and client's preferences. 
depends on account specifics, but I usually type 3-1/2 months NM
Subject: depends on account specifics, but I usually type 3-1/2 months NM


Depends on what ports you have on laptop and type of cable you have on the screen...sm
Subject: Depends on what ports you have on laptop and type of cable you have on the screen...sm

If you have the matching ports and cables, I believe you can do this.  I use my regular sized kb on my daughter's laptop all the time.  Should be the same concept?  If your screen has a usb cable, plug it into the laptop usb port.  The laptop should recognize the new hardware and "install" it. 


If you have a parallel port, the kind with the prongs that insert into the tower and then screws to tighten, you may have to install a parallel port into your laptop.  Don't know if this is as easy to do as on a desktop or not. 


what type of report is it?
Subject: what type of report is it?

is this an op report or H&P or what?
for what type of pain? what is the report about?
Subject: for what type of pain? what is the report about?

.
Got a body part? Report type? Something before and after this???nm
Subject: Got a body part? Report type? Something before and after this???nm

s
text before? after? context? type of report? help us help you... nm
Subject: text before? after? context? type of report? help us help you... nm


a type of fracture on a radiology report
Subject: a type of fracture on a radiology report

(Am new to radiology)  Pertaining to right elbow fracture:  S/L "desalergeeze" fracture. I have been trying to hear "distal ........ fracture" but it sounds like the above. Thanks so much.
What comes before or after this? Where in the dictation is this located? Type of report? nm
Subject: What comes before or after this? Where in the dictation is this located? Type of report? nm

s
How would I type a math equation in a report?
Subject: How would I type a math equation in a report?

Dictator said client answer 100 minus 7 as 93 after much calculation.  Should I use the minus and equal signs?  Thanks in advance....
I am not sure what type of report you are doing, but could it be amantadine and Zetia for the 2 meds
Subject: I am not sure what type of report you are doing, but could it be amantadine and Zetia for the 2 meds ?


Depends....
Subject: Depends....

I have an ortho doc that insists on using it the way the dictionary shows it, follow-up. He is not of old school, very young and a professor. Says it is his biggest pet peeve to see it ever used without the hyphen, and doesn't care much for BOS rules.

So, when in doubt, I do it exactly the way the dictator wants it no matter what I think.
think it depends on where you are...sm
Subject: think it depends on where you are...sm

like colour/color, theatre/theater, etc. i think "hiccups" is more common in usa.
Depends...sm
Subject: Depends...sm

It honestly depends on your employer's guidelines. Check with your Editor/QA staff. Sometimes there is just no way to make a doc make sense on paper without changing everything around and so it's easier just to really type verbatim; some docs only need a tweak here and there, so you really need to find out what 'verbatim' means as applied to the account you are working on.
Depends
Subject: Depends

One nurse's notes
Two (or more) nurses' notes
depends on the doc
Subject: depends on the doc

I worked for a chiropractor who wanted it disc but every other type of doc I've done wanted it disk
depends on how much.....
Subject: depends on how much.....

leeway you have.  With the comma there, it looks strange.  If you have to transcribe verbatim, I would put a hyphen....thus, * New patient - arm pain...*  If you have more leeway you could make a sentence * This is a new patient with a chief complaint of arm pain *.  If that is too much and looks like you are padding lines, then you could try just * New patient with arm pain *
depends on what it is...
Subject: depends on what it is...

a stroke could be evolving or completed....
Depends -- sm
Subject: Depends -- sm

I think it depends on the state where you want the information.

type for a hospital in Washington state, and they have a state licensure site with just about everything in the same site (i.e. physicians and physical therapists, nurses, etc. )

On the other hand, Arizona has only the doctors in its doctor database, and you have go to the Arizona physical therapist site to search for them.

Generally, when I first start typing a particular state, it takes a while to build up a set of search sites, but as I find them I add them to my favorites and then create a category for that state, so I don't have to search so much the next time.

Have a great day.
it depends
Subject: it depends

It depends on if it is modifying something.

The diameter of the wound is 1 cm.

There is a 2-cm length length discrepancy.

That's how I decide whether to hyphenate or not. On plural numbers, you can something tell if it should be hyphenated if it is said singular - i.e. six centimeters = 6 cm or six centimeter difference 6-cm difference

does that help?
Depends
Subject: Depends

Depends on the client preference. Generally, cardiorenal is accepted. Otherwise, it would be cardiac renal. I think he was just tripping.
Depends where you are from.. :-)
Subject: Depends where you are from.. :-)


Depends...
Subject: Depends...

I think it would depend on the specifics for that account - the hospital I work for would want it to read: 110 to 120 over 70 systolic.


Depends
Subject: Depends

I would not number unless doc states or your MTSO allows you to number arbitrarily, but kind of touchy with diagnoses, could confuse the issue. BUT I don't think it'd be wrong to number as follows:

1. INTERNAL DERANGEMENT, RIGHT KNEE.
2. TEAR OF LATERAL MENISCUS, RULE OUT MEDIAL MENISCUS TEAR.
3. EARLY DEGENERATIVE ARTHRITIS.

OR if you don't number, I'd punctuate:
INTERNAL DERANGEMENT, RIGHT KNEE. TEAR OF THE LATERAL MENISCUS. RULE OUT MEDIAL MENISCUS TEAR. EARLY DEGENERATIVE ARTHRITIS.

or you could put semi-colons in between.

But I'd put "DIAGNOSES." These are clearly more than one issue.
depends, does he say a few or 3?...sm
Subject: depends, does he say a few or 3?...sm

if he says a few then spell it all out, a few millimeters by a few millimeters as it is not a specific measure.  Also may need to drop the .0 on 3.0, most of the time trailing zero is dropped unless verbatim.   
depends on how it is being used
Subject: depends on how it is being used


depends
Subject: depends

It depends on what the client wants
It depends...
Subject: It depends...

If it's part of the name of the clinic (i.e., "Smith Family Planning Clinic"), yes.


If not, (i.e., "The patient went to the family planning clinic."), no.


depends
Subject: depends

They are hyphenated when as a group they form an adjective, a compound modifier. So it's an "over-the-counter medication" -- but the medication was purchased over the counter.

The medication is taken as needed, but it is taken on an as-needed basis.

Think of it this way: if you can substitute the phrase with "blue" and it makes sense, it gets hyphenated.
Depends on the doc...
Subject: Depends on the doc...

Patella tendinitis refers to the patella itself. Patellar tendinitis refers to the general area of the patella. They both actually are the same. Condyle-condylar. Patella-patellar. Interchangeable. I usually use the word that the doc does. There really is no difference except sometimes one sounds better in the context of the sentence. :-)
it depends...is it before or after the noun? sm
Subject: it depends...is it before or after the noun? sm

It could be "a 2-3-mm lesion," or "The lesion was 2-3 mm in size." Generally, cardinal numbers plus unit-of-measurement adjectives are hyphenated before the noun.
it depends on how it is dictated...sm
Subject: it depends on how it is dictated...sm

6600 (no comma) or 6.6 if they say it that way; if they say 6.6 thousand then you give them *6.6 thousand*


 


just trying to be funny here, but depends --sm
Subject: just trying to be funny here, but depends --sm

on WHICH "leg" he was referring to that was "nonpeeing." (sorry. couldn't resist) lol
Depends where you work
Subject: Depends where you work

and if they go by AAMT or not.
It really depends on whether the noun being
Subject: It really depends on whether the noun being

follows:

Austin-Moore-type prosthesis
prosthese is an Austin-Moore type
Depends on who you work for....
Subject: Depends on who you work for....

some don't like you to use hyphens some don't care. I have accounts that are both ways.
Depends on who's doing the feeling
Subject: Depends on who's doing the feeling

Sorry, dirty mind. 
And that depends on what the client wants. sm
Subject: And that depends on what the client wants. sm

I really think these are questions you should ask your employer, assuming this is work related. Style and rules can vary from company to company. Most will provide you with a list of rules or specs and sample reports. If they haven't, you might ask for that. When in doubt, I follow BOS guidelines, though.
Depends on the context
Subject: Depends on the context

Sometimes it simply means after and stands alone, other times it is used as a adjective or modifier, i.e.

The patient will follow up post discharge.

The patient will have post-discharge followup and labs.

One of those things you really have to think about, unfortunately :(
I really think it depends on the work...
Subject: I really think it depends on the work...

I have worked from home and been paid both by the line and by the hour (as I am now).  Unfortunately, the company was transitioning to voice recognition with us being paid half the line rate.  The VR program had loads of bugs and I'd take as long, if not longer, to edit a report as it would for me to have simply typed it outright and my money went down drastically.  It wasn't worth it and I quit (there was literally a mass exodus of MTs from this company when this happened). 


I now happily work by the hour doing both straight transcription, as well as QA and editing. 


Depends on your account. nm
Subject: Depends on your account. nm

nm
depends on context
Subject: depends on context

you can't have a bilateral eye, as it takes 2 to be bilateral. but, if it is followed by "surgery" then eye would be okay. I would base it on the context, there is no blanket answer.
depends if verbatim sm
Subject: depends if verbatim sm

I personally do not have strict verbatim accounts, so I would not put in the word systolic.  Since the doctor is putting in a range (110-120), he wants to make sure you know this is systolic.  I doubt it needs to be included.
Depends on account
Subject: Depends on account

My previous company had us leave the names out unless they were pertinent to the patient's care such as a caretaker. I.e. Dictated: Patient's wife, Susan, stated that. Transcribed: Patient's wife stated that. I would ask your QA about that to be sure though.
yes, depends on account
Subject: yes, depends on account

don't just go with the dictator-client may not be happy about it and you'll get in trouble. ask supervisor
i think it depends on the context...
Subject: i think it depends on the context...

if this is a psych report or they are questioning depression or PTSD then yes nontearful would be appropriate.
kind of depends, I think
Subject: kind of depends, I think

It sort of depends on your account specifics, I think.

If you type the whole report and still can't figure out which one it would be by using the context of the report, I personally would type the initials and then highlight them because that's what I do with my uncertain words on my account...don't know if that helps much....lol
Depends on context
Subject: Depends on context

If used as a verb it's "follow up." If used as a noun or adjective it's followup (or follow-up depending on your client's preference...mine wants followup for noun and follow-up for adjective).
Could you explain what it depends on please? sm.
Subject: Could you explain what it depends on please? sm.

I have been wondering the same thing. I was always told grade in arabic numbers and stages in roman numerals. Now I am confused too. LOL.
Another "it depends" . . .
Subject: Another "it depends" . . .

It's my understanding that if you are referring, as in your example, to a specific department at a specific hospital, yes; otherwise, no.

A common mistake, for example:

He went to the Emergency Room at University Hospital.

versus

He was seen in the emergency room for this problem once in 2006. (You don't know which exact emergency room at which exact hospital.)

A weird "irregular," just for fun(?):

Vocational Rehabilitation is an actual government agency.

Arrgh!