Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something lik
Posted By: tracy on 2008-09-30
In Reply to: tough one (sm) - moon1010
Subject: Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something like coronary obstruction artery "something" syndrome...? Just can't get it :( THanx though!
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MD states under Plan: All EKS were fast at six seconds times 2 to 3 times? HELP
Subject: MD states under Plan: All EKS were fast at six seconds times 2 to 3 times? HELP
Could very well be...hadn't thought of that
Subject: Could very well be...hadn't thought of that
nm
Could be. Just hadn't heard of it
Subject: Could be. Just hadn't heard of it
with a child this young.
I hadn't thought of that sm
Subject: I hadn't thought of that sm
That would be one way to do it. The doctors always seem to treat the phrases as a single entity, so I usually ponder it for a few minutes and then end up typing it the way they say it but wondered if it was correct or not.
I hadn't heard of that before, but it seems to be
Subject: I hadn't heard of that before, but it seems to be
spelled Valleix and involves the tarsal tunnel. Which is being examined, the foot/leg or the hand/wrist?
Thanks. Hadn't heard that one before. nm
Subject: Thanks. Hadn't heard that one before. nm
nm
you're right - I hadn't seen the words....nm
Subject: you're right - I hadn't seen the words....nm
Thanks! I hadn't run spell check yet ;)
Subject: Thanks! I hadn't run spell check yet ;)
I am familiar with it, but hadn't heard...
Subject: I am familiar with it, but hadn't heard...
of it on tonsil balls. Thanks, though.
My pleasure. I hadn't heard of that either. nm
Subject: My pleasure. I hadn't heard of that either. nm
:)
I wouldn't ask if I hadn't looked them up. sm
Subject: I wouldn't ask if I hadn't looked them up. sm
I found Ultracet in my drug book as an analgesic but I did not find Ultracef. However, on google it lists Ultracef as an antibiotic but I do not find it everywhere I look so I did not know if it was an approved medication.
That is why I asked.
I would agree with that if there hadn't been a specific
Subject: I would agree with that if there hadn't been a specific
dosage noted - that leads me to believe it's something the patient is taking.
...or two times or 2 times. Get some specs from QA. nm
Subject: ...or two times or 2 times. Get some specs from QA. nm
s
ah, yes, thanks. Hadn't spell checked the document yet.
Subject: ah, yes, thanks. Hadn't spell checked the document yet.
nm
Thanks! Hadn't heard it before, threw me for a loop.
Subject: Thanks! Hadn't heard it before, threw me for a loop.
sorry, see you already have bowel, so ? bubble, hadn't heard of that one.
Subject: sorry, see you already have bowel, so ? bubble, hadn't heard of that one.
Oh, I hadn't heard of that kind of hernia. Interesting! Thanks for the info. sm
Subject: Oh, I hadn't heard of that kind of hernia. Interesting! Thanks for the info. sm
I *almost* changed it to pants, and now I'm thinking I should have, but I went ahead and put "pantalones" as she dictated it. She definitely meant pants, not a type of hernia, as pt is a child having problems with soiling in his pants. Many patients for this account speak Spanish, so maybe the pt or his parents used the word "pantalones" (which is pronouned like "panta-lone-ess" in Spanish).
doubt
Subject: doubt
_____ (Evos) of a 40-year-old female who comes in to the office for follow up on chronic.....
You are without a doubt - sm
Subject: You are without a doubt - sm
a very unhappy person. I feel very sorry for you.
Any doubt
Subject: Any doubt
on vitals or med doses...ALWAYS A BLANK. :-)
equivocal - no doubt about it.....*LOL*
Subject: equivocal - no doubt about it.....*LOL*
Well, I doubt that would help her diet!!
Subject: Well, I doubt that would help her diet!!
I would - but I doubt they'd listen
Subject: I would - but I doubt they'd listen
If you're QA, though, I can nominate you for QA of the month! You deserve it.
Strongly doubt it
Subject: Strongly doubt it
nm
grammar doubt
Subject: grammar doubt
today for routine (follow up or followup) of hypertension.
grammar doubt
Subject: grammar doubt
follow up
doubt with radiology again
Subject: doubt with radiology again
Bony _____ (s* ---- tion) projects the distal right of the radial styloid process, which does not appear to be posttraumatic.
CT Brain doubt
Subject: CT Brain doubt
A 5-mm-thick _____ obtained through the brain with intravenous administration of contrast.
THANKS-don't you hate it when you doubt yourself?
Subject: THANKS-don't you hate it when you doubt yourself?
In degrees of ROM or in end range or ROM? I doubt sm
Subject: In degrees of ROM or in end range or ROM? I doubt sm
it is Dupuytren etc. nm
Thanks for replying. You confirmed it for me so no doubt now.
Subject: Thanks for replying. You confirmed it for me so no doubt now.
Ct abdomen and pelvis doubt
Subject: Ct abdomen and pelvis doubt
multiloculated or ____ (simi subtrated) cyst in the pancreatic map.
Doubt with cervical myelogram
Subject: Doubt with cervical myelogram
Dictating in 2 position:
1. _____(codstone) bone graft is in excellent position.
2. HIs ____(po*city) of bone formation along the edges of _____(c*stone) graft, which is unexpected in more cortical nature.
No, I doubt it since grip strength was 35/50..
Subject: No, I doubt it since grip strength was 35/50..
something else starting with a T that is only 11-12 pounds.
Using a question mark to indicate doubt or uncertainty sm
BOS says:
Use an ending question mark to indicate doubt or uncertainty.
Sometimes, particularly with diagnoses, a question mark is placed before a
statement in order to indicate uncertainty.
Placement either before or after the questionable material is acceptable, but
do not place the question mark both before and after.
Ex:
His cholesterol levels were high normal (or minimally elevated?).
D: Diagnosis: Angina question mark
T: Diagnosis: Angina?
or Diagnosis: ?Angina.
not Diagnosis: ?Angina?
Note: There is no space after the question mark in ?Angina.
=)
Rennie
www.renesue.com
I doubt highly that a stricture or lesion would
Subject: I doubt highly that a stricture or lesion would
improve a patient's nutritional status., but rather do the complete opposite. I think the physician meant to dictate "GI" physician since he/she mentioned the dysphagia in the dictation, which is also a common place for strictures or lesions to develop.
Client preferences rule here. If in doubt, sm
Subject: Client preferences rule here. If in doubt, sm
here's what I've always done:
He was given a do-not-resuscitate order.
I think my high school English teacher would prefer it thusly;)
He was given a "do-not-resuscitate" order.
Like Txczech said, sometimes these are bolded and capitalized to alert treating physicians of patients' wishes, similar to allergy statements. Client preference, again.
Unless you know for sure that the client does not have a special order called the Do-Not-Resuscitate Order, lowercase it. (I think this is what you might have been considering.)
Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again
Subject: Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again. nm
c
Meds and dosages scare me, so when in doubt...
Subject: Meds and dosages scare me, so when in doubt...
I always blank/flag it. 
Doubt you give 15 refills for narcotics.
Subject: Doubt you give 15 refills for narcotics.
x
I know this should be easy but I'm just not getting it (sm)
Subject: I know this should be easy but I'm just not getting it (sm)
Heart: regular rate and rhythm without murmur or s/l ek-a-pee. Thanks!
This has to be easy, I just can't get it(in ROS)
Subject: This has to be easy, I just can't get it(in ROS)
He goes through, giving negatives to everything, but I can't understand this last one.
"No hematochezia or melena. No abdominal pain. No skin changes, "da-rone" changes.
This is probably an easy one...
Subject: This is probably an easy one...
...but I cannot seem to figure it out:
Assessment:
Mild cognitive disturbance likely secondary to just what the patient thinks it is, namely anxiety, panic attacks, need for perfection, feels overwhelmed from having spent so many years dulling her senses with drugs and is now being bombarded by the S/L: STEH-ME-NOS OR STI-MIN-OSE of society.
Thanks for any help.
That was easy!
Subject: That was easy!
Really?! How come some sentences are like that? Thank you so much!!!
Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
Subject: Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.
Subject: I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.
That should have been ma's first move! easy look-up. nm
Subject: That should have been ma's first move! easy look-up. nm
;aljfd
An easy way to remember...
Subject: An easy way to remember...
If you can put an "a" in front of it, it is one word.
She a vascular followup.
She is here for followup.
2-words
She will follow up in one week.
She can follow up with me tomorrow.
sounds too easy..
Subject: sounds too easy..
Procedure: Apligraf placement to the left shin ulcer.
INDICATION: Nonhealing s/l menus (mean-es) ulcer, left shin.
Thanks.
Yes, the KVO allows easy access
Subject: Yes, the KVO allows easy access
warranted. In my experience, the KVO rate was used during a transesophageal echocardiogram wherein if the patient needed a bolus of a med, then the line was there to give it. Saline was given at a KVO rate, but I think it also (slow drip) allowed hydration for the patient while undergoing the procedure. I believe these drips given at KVO rate can be started a lot of times in the ER to allow venous access.
it's easy to hear that when they say
Subject: it's easy to hear that when they say
piperacillin.
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