You transcribe what he/she dictates.
Posted By: sm on 2008-10-09
In Reply to: still learning - The Queen
Subject: You transcribe what he/she dictates.
You transcribe the values as dictated. If he says "Cholesterol profile" and then just lists the values, then I would put a colon after profile and just list them.
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Yes. I transcribe for a cardiologist who always dictates
Subject: Yes. I transcribe for a cardiologist who always dictates
Under PMH. MD dictates: sm
Subject: Under PMH. MD dictates: sm
Status post trauma/repair to patient’s eye.
Would you leave this as is with the slash or change it? I am permitted to change things when necessary. Thanks.
What do you do when the doc dictates sm
Subject: What do you do when the doc dictates sm
... and I gave the patient 50 "mikes" of whatever medication. One said to spell it m-i-q-u-e-s, one said to use m-i-k-e-s, and one hospital said not to use it at all. So, does it stand for micrograms? Should we use slang? Aghh! Help, please.
I would put as doc dictates..sm
Subject: I would put as doc dictates..sm
if he says "calcium one every day" I would not input the q.d., but I would expand it as "calcium, one tablet every day." jmo and how I have been doing it with no complaints.
Exactly the way MD dictates it
Subject: Exactly the way MD dictates it
If the patient could see anything at all (I had one today where the patient could see 20/1760), then the MD would have given the value, but when there is nothing there, you just type nothing. I have a verbatim account, but even if I didn't, I still would not change it to 20/0 as that lone "0" could be mistaken as something else.
If a Dr. dictates
Subject: If a Dr. dictates
"posterior tib", meaning posterior tibial artery, do you type the abbreviation or go ahead and type out tibial?
if that's the way he/she dictates it...then yes I would. nm
Subject: if that's the way he/she dictates it...then yes I would. nm
xxx
The doctor dictates
Subject: The doctor dictates
His aortic valve appeared well-(s/l seated). I found some examples like that, but am unsure of certainty and spelling accuracy? Thank you in advance for any help.
Think that one is bad? my md dictates things like this...sm
Subject: Think that one is bad? my md dictates things like this...sm
I used a small, tiny, little Q-tip .... and he doesn't want me to change it. Bizarre!!!
I have a doc that dictates same thing
Subject: I have a doc that dictates same thing
mine means adenosine thallium
I leave it as whatever the doc dictates.
Subject: I leave it as whatever the doc dictates.
It's not my job to keep them politically correct.
Do I change it when he dictates cc? nm
Subject: Do I change it when he dictates cc? nm
!
I have a psychiatrist who dictates like that. sm
Subject: I have a psychiatrist who dictates like that. sm
I leave most of his stuff as is even though the account is not verbatim. A lot of times I end up wondering WTH he is talking about. When I first got his dictations I was going back to read and relisten because I thought I must have scrambled something. Give them what they dictate, if they don't like what they read maybe they'll take the time to think before they dictate next time.
when doc dictates L-thyroid sm
Subject: when doc dictates L-thyroid sm
Does he mean levothyroxine or Levothroid?
Dictates died s/l **min** CVA
Subject: Dictates died s/l **min** CVA
Dictates died from m-i-n CVA. I can't verify min CVA anywhere. Any suggestions?
dictates **phagiagram**
Subject: dictates **phagiagram**
He clearly dictates *phagiagram* or something that is VERY similar to that. I don't hear a *dys*. I tried google and am getting zero hits.
Do you think I should I QA it or would it be fine to just use *phagiagram*?
Thanks in advance.
I have an ESL who dictates a lipid profile
Subject: I have an ESL who dictates a lipid profile
and then says "lipid profile comment NIHN." What in the world does that mean?
whatever doc dictates. Would not use beats/minute tho. nm
Subject: whatever doc dictates. Would not use beats/minute tho. nm
Could be, although he only dictates 1 syllable. I think I will flag. Thanks.
Subject: Could be, although he only dictates 1 syllable. I think I will flag. Thanks.
provider dictates bivicd sm
Subject: provider dictates bivicd sm
Would you put bi-V ICD, biV-ICD, bi-V-ICD or something else? Says it multiple times in note. Thanks!
dictates ureteral meatus
Subject: dictates ureteral meatus
Could that be right? Or do you think dictator means urethral? Talking about vesicoureteral reflux in a male.
Thanks!!!
Is it Mersa or MRSA? he dictates
Subject: Is it Mersa or MRSA? he dictates
Doc dictates 3/5 systolic murmur (sm)
Subject: Doc dictates 3/5 systolic murmur (sm)
I always thought the last number was 6. Does this make sense? TIA!
The patient has MS, dictates she cannot s/l antigravitate the leg.
Subject: The patient has MS, dictates she cannot s/l antigravitate the leg.
Have not heard the term antigraviate before, and cannot find it anywhere. That is all the context I have
grr. doc dictates s/l alipta, spells a-l-m-i-t-a. sm
Subject: grr. doc dictates s/l alipta, spells a-l-m-i-t-a. sm
It's a second choice chemotherapy agent after carboplatin/Taxotere rejected by patient. Any thoughts?
Many thanks in advance!
dictates what sounds like omPUREizole
Subject: dictates what sounds like omPUREizole
I'm not finding this anywhere. Anyone have a clue?
Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!
Subject: Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA!
dictates glucocheck/glucochecked
Subject: dictates glucocheck/glucochecked
Is that right? I can't 100% verify.
Thank you.
Your choice unless client dictates different.
Subject: Your choice unless client dictates different.
Okay, I'm not explaining right. Doc actually dictates "Positive Hepatitis CAB". nm
Subject: Okay, I'm not explaining right. Doc actually dictates "Positive Hepatitis CAB". nm
In Vital SIgns, doc dictates "MAP 77". ?? sm
Subject: In Vital SIgns, doc dictates "MAP 77". ?? sm
VITAL SIGNS: Temperature 36.0, pulse rate 62, respiratory rate 16, systolic 112, diastolic 160, MAP 77.
I work for a general surgeon who dictates...sm
Subject: I work for a general surgeon who dictates...sm
sestamibi scan on all his parathyroid patients...........
and google to back it up:
Sestamibi Scan for parathyroid disease and Sestamibi x-ray for parathyroid tumors. The Sestamibi scan finds the diseased parathyroid gland.
www.parathyroid.com/sestamibi.htm - 49k - Cached - Similar pages |
Sestamibi Scan for parathyroid disease and hyper-parathyroid disease. The parathyroid Sestamibi scan finds the diseased parathyroid gland and can be used ...
parathyroid.com/Sestamibi-Technical.htm - 65k - Cached - Similar pages |
Hgh quality sestamibi scan shows a single parathyroid adenoma. ... The Sestamibi scan will display the hyperactive gland which is causing ...
www.endocrineweb.com/sestamibi.html - 9k - Cached - Similar pages |
A sestamibi scan of the parathyroid gland is a nuclear medicine procedure which is performed to identify hyperparathyroidism (or parathyroid adenoma). ...
en.wikipedia.org/wiki/Sestamibi_scan - 17k - Cached - Similar pages |
Doctor dictates Actos plus met 15/850 mg daily. nm
nm
Doc dictates that blood sugars are in the one-teens SM
Subject: Doc dictates that blood sugars are in the one-teens SM
How would you type it? TIA
He dictates in SOAP format so that might look out of place.
Subject: He dictates in SOAP format so that might look out of place.
Dictates doesn't have a *dysconjative* gaze
Subject: Dictates doesn't have a *dysconjative* gaze
Thanks!
he is dictating is backwards. I would type it as he dictates...nm
Subject: he is dictating is backwards. I would type it as he dictates...nm
xx
doctor dictates and spells cellulagia
Subject: doctor dictates and spells cellulagia
I cannot find or verify this anywhere. Is this even a word?
Type it exactly as the doctor dictates, verbatim....nm
Subject: Type it exactly as the doctor dictates, verbatim....nm
nm
Formatting when doctor dictates "question..."
Subject: Formatting when doctor dictates "question..."
Dictated: "Patient was prescribed question Pyridium"
How would I transcribe this? Would I type, "Patient was prescribed Pyridium?"
Thanks in advance!!!!!!
that sounds right..doc dictates dilantin level in the labs....thanks!
Subject: that sounds right..doc dictates dilantin level in the labs....thanks!
Patient has sebaceous cyst, doc dictates s/l hidranidus.
Subject: Patient has sebaceous cyst, doc dictates s/l hidranidus.
Thanks
dictates: has seborrheic keratoses**rejuvinal** nevi
Subject: dictates: has seborrheic keratoses**rejuvinal** nevi
My MD dictates all the time, "perimenopausal symptoms" I can't document. Should I type it
Subject: My MD dictates all the time, "perimenopausal symptoms" I can't document. Should I type it anyway?
Doc dictates s/l Aluin but spells Alleyn for wound care....
Subject: Doc dictates s/l Aluin but spells Alleyn for wound care....
with an unna boot...anyone know what this could be? Can't find any wound care info....Alluin is what is sounds like to me...TIA!!!
Cardio. Dictates ostium to TM in Impression. Can't find expansion...
Subject: Cardio. Dictates ostium to TM in Impression. Can't find expansion...
that makes sense in any references and nothing in rest of dictation that connects. Got any ideas?
Gracias!
Also dictates the patient had scoliosis diagnosed at 10 years of age, no treatment (is now 60)
Subject: Also dictates the patient had scoliosis diagnosed at 10 years of age, no treatment (is now 60)
Drug help please!!! s/l Enamulex. Dr. just dictates a list of meds without a diagnosis for it.
Subject: Drug help please!!! s/l Enamulex. Dr. just dictates a list of meds without a diagnosis for it.
The doc dictates under ROS, GU: The patient denies issues with polyuria POLYPHASIA, or polydipsia..
Subject: The doc dictates under ROS, GU: The patient denies issues with polyuria POLYPHASIA, or polydipsia..
is this correct? POLYPHASIA???? Isn't POLYPHAGIA having to do with eating/swallowing? I can't find anything in google relating to urination or GU system.....
 Thanks in advance!!
Physical therapist dictates measurement at 10-1/2 degrees (how do you put the half degree)? (nm)
Subject: Physical therapist dictates measurement at 10-1/2 degrees (how do you put the half degree)? (nm)
Dictates, we are working on (s/l) "preos" forms since the patient cannot afford Cymbalta. nm
Subject: Dictates, we are working on (s/l) "preos" forms since the patient cannot afford Cymbalta. nm
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