When transcribing "Sister so-and-so, when dictator refers
Posted By: joan on 2007-07-11
In Reply to:
Subject: When transcribing "Sister so-and-so, when dictator refers
to patient as "sister" throughout report, is "sister" capitalized or not? Neither way looks correct to me.
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If he just saying "Sister" and not using proper name afterwards
Subject: If he just saying "Sister" and not using proper name afterwards
then I would capitalize. But if he is saying "Sister Mary Frances" then I would use "Sr."
holiday...is the dictator an Arab dictator? nm
Subject: holiday...is the dictator an Arab dictator? nm
x
type what dictator said, dictator is not incorrect.....
Subject: type what dictator said, dictator is not incorrect.....
.
I am transcribing
Subject: I am transcribing
That is a very good point. I will type it the way she dictates. Thanks for the help.
no, maybe not - maybe they're transcribing ESL doc
Subject: no, maybe not - maybe they're transcribing ESL doc
are you transcribing or coding?
Subject: are you transcribing or coding?
If you are transcribing, the correct way is:
V code: Parent-child conflict.
Unless you are a certified coder, it would be wise to avoid inserting the actual code into the transcription as the MD/psychologist did not dictate it. The codes can change from year to year and you could enter the wrong code depending on the date of the service and which coding resource you are using.
I am transcribing a report
Subject: I am transcribing a report
on a child. The doctor is stating that she gave s/l 2 to 1 neb? Is this what I am hearing? TIA
I have been transcribing "supertherapeutic." (sm)
Subject: I have been transcribing "supertherapeutic." (sm)
super = excess, above, but often the same usage as "supra." (Stedman's).
Are you by chance transcribing a dictation of Dr. A. S?
Subject: Are you by chance transcribing a dictation of Dr. A. S?
help transcribing measurement STAT
Subject: help transcribing measurement STAT
I know that I know this somewhere in my head, but I can't think of it to save my life
How do I transcribe "twelve one-hundreths of an inch"?
TIA!!
Advice for transcribing lens
Subject: Advice for transcribing lens
I am new and have an ophthalmology account. I am not having much trouble with the terms, but I'm unsure how to punctuate and/or format the lens prescriptions. Does anyone know of a good website that explains this or provides examples? Thanks!
QE&A - anyone know what this refers to?
Subject: QE&A - anyone know what this refers to?
I know the phrase is what is dictated because I sent to QA the first time I heard it. I have a doc who says it infrequently. I can't document it and am just curious.
THANKS!
Thank you so much! I now realize I have at times been transcribing wrong. nm
Subject: Thank you so much! I now realize I have at times been transcribing wrong. nm
!
I never heard strandy until I started transcribing sm
Subject: I never heard strandy until I started transcribing sm
for one of my current radiologists. He says "strandy" plain as day, so that's what I put. Grates on my nerves, but he's the radiologist.
To be perfectly honest, I have never seen it with periods before and I have been transcribing for 34
Subject: To be perfectly honest, I have never seen it with periods before and I have been transcribing for 34 years, but I too still have to learn new things every day. Guess that is what keeps me motivated.
0.2 to 0.22 (think it refers to seconds)
Subject: 0.2 to 0.22 (think it refers to seconds)
Dr. doing laminectomy and refers to
Subject: Dr. doing laminectomy and refers to
xxxx
transcribing about NIDDM. Sounds like sulfanuria and glybizone.
Subject: transcribing about NIDDM. Sounds like sulfanuria and glybizone.
I've come across a dictation that is talking about NIDDM. It sounds like he's saying "he was initially of sulfanuria and switched insulin in Puerto Rico". The other part is "He has never been on metformin or glybizone." Any suggestions??
nephritis refers to the kidneys
Subject: nephritis refers to the kidneys
so not sure.
Dr. doing cervical laminectomy and refers to SM
Subject: Dr. doing cervical laminectomy and refers to SM
s/l Kafnicks tubercle. I cannot find this and I have looked under several spellings.
Thank you.
Could be, heme just refers to blood. NM
Subject: Could be, heme just refers to blood. NM
x
Maybe just refers to putting mesh
Subject: Maybe just refers to putting mesh
at the 12 o'clock, 3 o'clock, etc. positions? Weird. Never heard that one before.
Believe it would be tenting. Tinting refers
Subject: Believe it would be tenting. Tinting refers
to color changes, tenting is referring to "poking up or out" of the skin.
In eight years of transcribing ortho, I've never heard this term...
Subject: In eight years of transcribing ortho, I've never heard this term...
Impression:
1. Left de Quervain tendinitis.
2. Left carpal tunnel syndrome.
Will get EMGs. The patient has evidence of s/l palmarthrorheumatosis. He runs it together, so it may be palm (or palmar) arthrorheumatosis.
Any help is appreciated. :)
but encephalopathic refers to the brain, not knee???? nm
Subject: but encephalopathic refers to the brain, not knee???? nm
Probably refers to staples--white load, maybe? nm
Subject: Probably refers to staples--white load, maybe? nm
x
it is adverse lie. refers to how the testicles lay in the scrotum.
Subject: it is adverse lie. refers to how the testicles lay in the scrotum.
nm
pepto refers to stomach so peptoesophageal
Subject: pepto refers to stomach so peptoesophageal
is same as gastroesophageal. There is cecectomy for exicision of cecum.
Break the word down - osteo refers to
Subject: Break the word down - osteo refers to
bone and condyle is a part of the bone as per femoral condyle, lateral condyle etc. so yes it is a word.
Maybe sibilant -- Somnolent refers to awareness/
Subject: Maybe sibilant -- Somnolent refers to awareness/
neurologic state of a patient.
Correction: Cytotec (ulcer med).It's the lateness of the hour. Thought I was transcribing alone.
Subject: Correction: Cytotec (ulcer med).It's the lateness of the hour. Thought I was transcribing alone.
x
Transcribing ESL. He is pretty clear, but does 15 cc fluid restriction sound a little severe??? (nm)
Subject: Transcribing ESL. He is pretty clear, but does 15 cc fluid restriction sound a little severe??? (nm)
x
ray refers to the digits...toes, fingers, etc..not patellae..sm
Subject: ray refers to the digits...toes, fingers, etc..not patellae..sm
does not make any sense.
a or an refers to the SOUND of the word, not necessarily a vowel
Subject: a or an refers to the SOUND of the word, not necessarily a vowel
therefore YURanalysis sounds like it has a consonant and so A is used. With MI and MRI, it sounds like EM-I or EM-R-I. It sounds like a vowel and so AN is used.
on a quick search, it seems Atar refers to a drug RX
Subject: on a quick search, it seems Atar refers to a drug RX
can't be certain, but that does fit the context of the sentence. "if the patient doesn't have *a prescription drug supplement coverage plan*"
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?
Third-spacing is correct. Refers to fluid shift
Subject: Third-spacing is correct. Refers to fluid shift
to interstitial space.
Dont know, but "sharp" usually refers to optic disc
Subject: Dont know, but "sharp" usually refers to optic disc
nm
is this dictator ESL (foreign dictator)?....
Subject: is this dictator ESL (foreign dictator)?....
if ESL, I would either blank him or give him that Avodart but the other one I haven't a clue and would have to blank there too. Sorry :(
apoptotic ? refers to cellular changes which may result in a gait disturbance. nm
Subject: apoptotic ? refers to cellular changes which may result in a gait disturbance. nm
nm
And by the way, PLEURAL refers to thelining of the lungs, PLURAL means ore than one. have not heard
Subject: And by the way, PLEURAL refers to thelining of the lungs, PLURAL means ore than one. have not heard of pleural effusion, etc????
nm
when transcribing "baby girl Smith" should baby girl be capitalized?
Subject: when transcribing "baby girl Smith" should baby girl be capitalized?
We have been caught by our QA for transcribing Toprol XL instead of Toprol-XL Since there is
Subject: We have been caught by our QA for transcribing Toprol XL instead of Toprol-XL Since there is
technically not a drug called Toprol should this be transcribed as Toprol-XL though dictated as only Toprol. Have not been called on this yet, but just wondering what others do.
Help - not an ESL dictator.....sm
Subject: Help - not an ESL dictator.....sm
Anglo mushmouth cardiologist is saying:
This 85-year-old white male was admitted and had a posterior s/l *A to E* resection for rectal carcinoma.
I am not sure he is saying *A to E* and I already googled this to no avail.
TIA for any light anyone can shed on this....really appreciate it...
Dictator says ...
Subject: Dictator says ...
She has a history of being intolerant of an ACE and s/l RHAB. She says it like a word, so it s/l Are ab
I pretty sure it's an abbreviation like ACE, but I can't make out the exact letters to even know what to look up to be sure. TIA!
When a dictator says Cor S1 and S2, how...sm
Subject: When a dictator says Cor S1 and S2, how...sm
should that be typed? Coronary: S1 and S2?
This must be something the dictator often says. sm
Subject: This must be something the dictator often says. sm
Can "preson" be "perfusion?"
"perfusion to tissues?"
"present 2+ pulses?" (awkward)
What are the sentences before and after? Do you have any other PEs from this dictator?
Is this an orthopedic exam or general PE?
Dictator says...
Subject: Dictator says...
CBC showed WBC of fourteen point six thousand.
What is the correct way to type this number?
is the dictator ESL? perhaps not saying N
Subject: is the dictator ESL? perhaps not saying N
You could be right as the dictator is ESL. Thank you. NM
Subject: You could be right as the dictator is ESL. Thank you. NM
two more for same dictator pls sm
Subject: two more for same dictator pls sm
Patient without evidence of a left atrial s/l apinich thrombus.
The patient underwent s/l durakyto cardioversion.
VERY fast talker. Any ideas?
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