Who specifies no personal info? Type what the dictator says. SM
Posted By: tulip on 2008-04-30
In Reply to: naming relatives in H&P? - bborton
Subject: Who specifies no personal info? Type what the dictator says. SM
The responsibility is in the hands of the dictator. If he or she dictates it, then give it to them... plain and simple.
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Personal opinion, but I would only makes this a "header" within a report if the dictator state
Subject: Personal opinion, but I would only makes this a "header" within a report if the dictator states to do so, otherwise I would just type it verbatim in paragraph format.
Some accounts want no personal info
Subject: Some accounts want no personal info
at all in the report, others want pertinent people listed. It depends on the facility/account.
type what dictator said, dictator is not incorrect.....
Subject: type what dictator said, dictator is not incorrect.....
.
on the rare occasion that a dictator does say it that way, I type it that way (10.9 thousand)
Subject: on the rare occasion that a dictator does say it that way, I type it that way (10.9 thousand)
Per AAMT BOS you should use the number (2) unless client specifies otherwise....nm
Subject: Per AAMT BOS you should use the number (2) unless client specifies otherwise....nm
Strep throat is fine unless client specifies
Subject: Strep throat is fine unless client specifies
xx
more info please?? what body type?
Subject: more info please?? what body type?
,
more info please? type of cancer or name of staging system? nm
Subject: more info please? type of cancer or name of staging system? nm
any more info? Type of exam, chief complaint, anything at all.
Subject: any more info? Type of exam, chief complaint, anything at all.
dd
holiday...is the dictator an Arab dictator? nm
Subject: holiday...is the dictator an Arab dictator? nm
x
what is your source? personal opinion?
Subject: what is your source? personal opinion?
x
ahh, it is a personal issue - then take it private!
Subject: ahh, it is a personal issue - then take it private!
XX
Client or personal preference
Subject: Client or personal preference
You have several choices here that are correct. You can put E:A reversal, E/A reversal, or E to A reversal. If no client preference, your pick - all are correct.
No, I cannot confirm. I have some personal notes
Subject: No, I cannot confirm. I have some personal notes
that I make and had Segund in them.
Personal History is correct
Subject: Personal History is correct
nm
My personal favorite is "aspirational pneumonia." :)
Subject: My personal favorite is "aspirational pneumonia." :)
x
Personal opinion, I hyphenate it as tib-fib fracture
Subject: Personal opinion, I hyphenate it as tib-fib fracture
Just personal for me, but I have always typed it Sitzmark study
Subject: Just personal for me, but I have always typed it Sitzmark study
D: personal history of colon polyps
Subject: D: personal history of colon polyps
That's exactly how it was dictated. While all this stuff is "personal," am I missing something here?
Can you please provide the sentence? Or is question of a personal nature?
Subject: Can you please provide the sentence? Or is question of a personal nature?
x
Personal opinion I would hyphate it as supra-SMAS
Subject: Personal opinion I would hyphate it as supra-SMAS
wild guess s/l personal synovarment syndrome
Subject: wild guess s/l personal synovarment syndrome
Right CMC joint arthrosis and s/l personal synovarment syndrome.
Personal opinion but I believe it is distal as in determination (i.e. the dorsalis pedis artery puls
Subject: Personal opinion but I believe it is distal as in determination (i.e. the dorsalis pedis artery pulse can be palpated readily lateral to the extensor hallucis longus tendon on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation.)
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 :(
same here. Type out numbers at beginning of sentences. Otherwise type numeral if in sentence itself.
Subject: same here. Type out numbers at beginning of sentences. Otherwise type numeral if in sentence itself.
nm
Patient with type 2 diabetes prescribed a s/l glutisone type drug. nm
Subject: Patient with type 2 diabetes prescribed a s/l glutisone type drug. nm
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?
I bet you that you are right though, it is an ESL dictator
Subject: I bet you that you are right though, it is an ESL dictator
and I think he is just flipping through the chart giving me every med she ever had not realizing they are one in the same. I will flag it anyway. You are awesome thank you!
could the dictator be SM
Subject: could the dictator be SM
stumbling over words and saying something like:
First, today I am giving him Vicodin and Skelaxin.
?? Just guessing. Never heard of first aid being used in that way, but I suppose it could be...?
If dictator says
Subject: If dictator says
"blood pressure was in the 140s 150s". How do I type this?
But if the dictator is saying the "A" it has to be
Subject: But if the dictator is saying the "A" it has to be
x
Dictator says:
Subject: Dictator says:
Abdomen is nondistended. No 'LKF' felt. Then he says 'BJE', the patient's abduction is normal.
What is LKF or is the acronym something different?
What does BJE stand for? He is clearly saying 'BJE', but I am not sure about 'LKF'. I still would like to know what BJE means. Thanks
Could the dictator be saying "CU" as in sm
Subject: Could the dictator be saying "CU" as in sm
"cystourethroscopy?"
Need quick help with this dictator please
Subject: Need quick help with this dictator please
This doctor just said
"Initial white blood count was elevated at 12.7 thousand."
Do I transcribe it like that, or do I put 12,700?
TIA!
Dictator said keep LDL cholesterol less than ...sm
Subject: Dictator said keep LDL cholesterol less than ...sm
70 per ----- guidelines. He rambled off a bunch of initials and slowing him down only made it worse. I think the last 3 were CHA. TIA!
Am I hearing this right. Could the BP be 129/135 (ESL dictator)??? (nm)
Subject: Am I hearing this right. Could the BP be 129/135 (ESL dictator)??? (nm)
Dictator kept saying polynephritis ... sm
Subject: Dictator kept saying polynephritis ... sm
but I couldn't find that. Did she mean pyelonephritis? There were a lot of renal references in report. TIA!
Is the dictator foreign?
Subject: Is the dictator foreign?
I wonder if they're saying Ativan. Some of my foreign dictators say it as "Ati-won". Just a thought!
maybe dictator meant to say....nm
Subject: maybe dictator meant to say....nm
could dictator be saying appendectomy?
Subject: could dictator be saying appendectomy?
Without further context, I'd say the dictator was saying sm
Subject: Without further context, I'd say the dictator was saying sm
"gassiness and indigestion" or possibly "gaseous distention" which is verified in the GI Stedman's.
?? Dictator is saying "technique" twice in a row? nm
Subject: ?? Dictator is saying "technique" twice in a row? nm
x
Mumbly dictator...med s/l
Subject: Mumbly dictator...med s/l
The patient has a problem with peripheral neuropathy and the _____ (s/l payomide) was refilled. A1c is pending.  mumblers today!!
Dictator confusing....sm
Subject: Dictator confusing....sm
I have a dictator that dictated in two different reports.. "No CVA angle tenderness." and the same dictator in another report states "No CV angle tenderness." I am confused as to which is the correct way ?
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