You don't use slang in a diagnosis section
Posted By: don't ya know - nm on 2006-05-13
In Reply to: so what if it's slang - if the dictator says *mets* - nm - and it's a verbatim account, they get *mets*
Subject: You don't use slang in a diagnosis section
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It is listed in the diagnosis section and (sm)
Subject: It is listed in the diagnosis section and (sm)
the history is that the patient has had 4 preterm deliveries (all 32 weeks and less) by cesarean section and presented for contractions. she has been on 17-alpha hydroxxyprogesterone since week 16, but no mention of her present week gestation. she was sent home on bedrest with the injections and cervical length measurement
quick section (as in frozen section) is correct.
Subject: quick section (as in frozen section) is correct.
x
Yes, trich is slang. Ask your QA person what to do with slang. nm
Subject: Yes, trich is slang. Ask your QA person what to do with slang. nm
x
C-section or cesarean section sm
Subject: C-section or cesarean section sm
Not cAesarean section - contrary to popular belief, it was not named after Julius Caesar.
C-section or cesarean section nm
Subject: C-section or cesarean section nm
Please help. It is in the ROS section (SM)
There has been no eye inflammtion. No problems with alopecia. There has been no eye inflammation. No s/l "sick ahm plot" complex or oral lesions.
Can't figure this out. Thank you for any help you might be able to offer.
Chickadee 
c-section
Subject: c-section
pt with McDonald's cerclage and frank breech presentation with sl-ancervical dilatation.
C-section
Subject: C-section
At the time of cord clamp sl-all I can hear is "sol" at the end 2 grams is given in the OR to the patient
C section
Subject: C section
PAST SURGICAL HISTORY: C section or C-section ?
C-section. nm.
Subject: C-section. nm.
nm
please help with OB C-section
Subject: please help with OB C-section
I don't usually type OP reports, but I got this one and need a little help with a C-section. It's a primary low-flap transverse C-section due to breech presentation.
He says the rectus muscles were separated and taken down. Then: The superior most aspect of the s/l "perineum" was nicked. Thought this should be peritoneum.
Then: Bowel floor s/l "was placed" a low marginal incision.
any help?
Doing a C-section, doc says SM
Subject: Doing a C-section, doc says SM
the IFE was attached and removed after vertex was delivered. What is IFE? Thanks.
C-section help
Subject: C-section help
The scalpel was then used to make curvilinear hysterotomy, through which the infant was delivered and was s/l dooley ? suctioned.
c-section - nm
Subject: c-section - nm
C-section with s/l DPS?
Subject: C-section with s/l DPS?
Status post primary low transverse cesarean section with s/l DPS.
Other diagnoses include:
Uterine pregnancy at 39 weeks and 1 day gestation.
Breech presentation.
Multiparous desiring permanent sterilization.
Anemia.
c-section or C-section?
Subject: c-section or C-section?
no, don't think its slang
Subject: no, don't think its slang
probably is saying after his visit for congestion -- then ...bla bla bla
Because it's slang
Subject: Because it's slang
It get's used enough, that I think most of us type it, and it will end up in the dictionaries before long. But it is still slang. Somebody has taken the Latin ending and just slapped it onto an English slang word. Doesn't it sound better than "increased numbers of immature, unsegmented neutrophils"?
Slang
Subject: Slang
He does nto say the trichomonas just trich is that a slang medical word?
Slang
Subject: Slang
The account specifics for my hospital are that you must type what the doc says. I don't like it sometimes, but I do it - alk phos, A-fib, bicarb, crit . . .
dip? (slang?) SM
Subject: dip? (slang?) SM
The dictator says "dip" in the social history (see sentence below). I think this is slang for something but I am so not cool and I'm not sure what it is. My DH thinks it might be chew tobacco?
"She quit smoking over 30 years ago. She did "dip" up until 1 year ago. There is no alcohol or drug use."
TIA!
as far as I now, it is slang for
Subject: as far as I now, it is slang for
regurgitation, but you may be under verbatim rules, in which case it would regurge. I think it is slang, but that's just me.
slang
Subject: slang
Dr. says "Penrose s/l dc'ed today."
Patient had his Penrose drain removed at the visit. I'm assuming she is using some kind of slang/shorthand (whatever you want to call it), but it's a new one for me. Any ideas?
TIA
If you can use slang, like that other
Subject: If you can use slang, like that other
than changing the On to OF. or if you cannot use slang "X-rays taken OF bilateral tibias and fibulas.
Caesarean section
Subject: Caesarean section
I am having an extremely difficult time understanding a doctor with an accent. The fascia was opened in the tremboralis manner. I'm not sure if he's saying in, on or under and the other word, I have no clue. Help! Thanks.
cesarean section
Subject: cesarean section
temporalis fascia??
permanent section?
Subject: permanent section?
Typing a C-section OP sm
Subject: Typing a C-section OP sm
This incision was extended bilaterally using s/l Danish scissors.
C-section OP note...
Subject: C-section OP note...
s/l he is saying atanic contractions. TIA!
OB question - C-section
Subject: OB question - C-section
Light meconium noted with s/l full or four waters. Full? Can't find it anywhere. TIA!
C-section term
Subject: C-section term
The infant's head delivered s/l "in call."
Thanks.
C-section term
Subject: C-section term
That's it. Thanks for your help everyone!
that's the section m docs usually put it in.
Subject: that's the section m docs usually put it in.
(PS: The patient is about to have a C-section.) -nm
Subject: (PS: The patient is about to have a C-section.) -nm
nm
It was under the impression section
Subject: It was under the impression section
I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
permanent section??
Subject: permanent section??
x
frozen section? nm
Subject: frozen section? nm
.
Would this be safe during a C-section
Subject: Would this be safe during a C-section
Thanks
C section question - sm
Subject: C section question - sm
Dictated: "The skin was then closed with staples, and new skin was applied." Help with new skin? Thanks!!
is it in the respiratory section?
Subject: is it in the respiratory section?
Thanks, it is a cesarean section.
Subject: Thanks, it is a cesarean section.
No I don't have a demographic section, only sm
Subject: No I don't have a demographic section, only sm
The history section and a PE section along with x-rays and plan section. I hope this helps.. :-)
Leg length is roughly measured from the anterior-superior iliac spine to the medial malleolus. It is measured on the left side at 37-3/4 and on the right side at 37 inches even. Again, this is a rough measurement.
Neb is slang for nebulizer. nm
Subject: Neb is slang for nebulizer. nm
xx
I think this is a new slang. Never heard anyone else use it. nm
Subject: I think this is a new slang. Never heard anyone else use it. nm
x
diabetologist - new slang
Subject: diabetologist - new slang
.
thank you ! that must be it - yea slang gets me every time !
Subject: thank you ! that must be it - yea slang gets me every time !
slang question
Subject: slang question
Doc dictates [s/l maxt out] credit cards. Of course, Word is highlighting every spelling, but I'm trying to figure out which looks best.
A. Maxed out
B. Maxxed out
C. Max'ed out
D. Any other suggestions?
Thanks!
Ask your QA. When I get that slang I use "endoclipped." nm
Subject: Ask your QA. When I get that slang I use "endoclipped." nm
x
Thank you both. I was worried it was too slang.
Subject: Thank you both. I was worried it was too slang.
doc slang for lytic?
Subject: doc slang for lytic?
n/m
I'd call that slang and
Subject: I'd call that slang and
I'd probably change it to "... and he received approximately 40 stitches" unless I was on verbatim.
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