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Your thoughts on how to correctly transcribe this.

Posted By: Indastix on 2008-06-06
In Reply to:

Subject: Your thoughts on how to correctly transcribe this.

One doc always says "sub 1st metatarsal" (or 2nd, 3rd, etc).  Should it be sub 1st metarsal, sub-1st metatarsal, 1st submetatarsal or...?


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yep, means no sinful thoughts or fearful/punishment thoughts.
Subject: yep, means no sinful thoughts or fearful/punishment thoughts.


my first thoughts as well....sm
Subject: my first thoughts as well....sm

but I thought it was strange as they have never said this phrase before.  Sending to QA and see what they think - will keep you posted. 
same thoughts
Subject: same thoughts

I looked up those same definitions. I actually had typed adverse.
Ahhhhh!
Thanks, I will listen again.
My thoughts....
Subject: My thoughts....

That's what I kept finding in doing my research, but like I said that guy needs to speak clearer English......but I guess that would be too easy.  Ha-ha!


Thanks for verifying what I had put down.  I will get this some day, but I am new and just learning.  Thanks for bearing with me.


my thoughts exactly! :)
Subject: my thoughts exactly! :)


My thoughts on this
Subject: My thoughts on this

Diagnoses #1 and #2 sound like they might be both referring to the left knee. #3 sounds like a new thought process to me. My guess on this would be contingent on how the dictation sounded. Is the dictator pausing between 1 and 2? Numbering 1 and 2? If he isn't, my thought would be this:

1. Left knee lateral meniscus tear; osteochondral defect.
2. Right knee degenerative joint disease.
You're welcome and my thoughts
Subject: You're welcome and my thoughts

exactly.  Some people just have to be huffy I guess.  Hang in there. 
a couple of thoughts
Subject: a couple of thoughts

First to address the issue of subcu - Joint Commission created a list several years ago that deals with this wording - and JC trumps BOS.  From Joint Commissions List of Dangerous Abbreviations:


Abbreviation: S.C. or S.Q. (for subcutaneous)


Potential Problem:  Mistaken as SL for sublingual, or "5 every"


Preferred Term:  Write "Sub-Q", "subQ", or "subcutaneously"


As far as what the man was trying to express to you was his opinion that truncated words (partial words used to express a complete word) should be avoided.  Trach is not a word.  Trachea, tracheostomy, etc., are words.  Alk is not a word.  Alkaline is a word.  There are also lab and other words that are commonly acceptable in their abbreviated form, such as INR, CPAP, MRI, etc.


There are acceptable abbreviations of certain words that are commonplace.  For example, lab is widely accepted to represent laboratory.  Exam is acceptable to represent examination.  HIV is another example.


If you understand the difference between the use of an abbreviation and avoiding the use of truncated words, your work will reflect a much clearer intent of the dictation.


Your company needs to decide which side of the fence it wants to sit on, and it appears there may be some changes in your QA future.  If this man is in charge of QA and you want to continue working there, you might want to begin taking note of what he is saying.


my thoughts exactly. No wax in the nose. Not now, not ever. Maybe sm
Subject: my thoughts exactly. No wax in the nose. Not now, not ever. Maybe sm

sinusitis can CAUSE cerumen impaction in the ears but NOT in the nose.
anybody have any thoughts on the traction ??
Subject: anybody have any thoughts on the traction ??

s/l kleinharts traction
Rudd, you and your family will be in my thoughts. sm
Subject: Rudd, you and your family will be in my thoughts. sm

I hope your step-son is back soon, safe and sound. Keep us informed. Thinking good thoughts for you.
Is it two different dx or thoughts, i.e. appendiceal, cystocele...
Subject: Is it two different dx or thoughts, i.e. appendiceal, cystocele...


two thoughts; unsure how helpful, but,
Subject: two thoughts; unsure how helpful, but,

This is 1 of many definitions from an "URBAN" dictionary: MACK

mack is a flexible word as a verb; it can be used in pretty much any situation and its meaning will be understood.
Thus, in your case, maybe the dictator chose the word mack as slang for height?.....because 23.5 cm is equal to 9.25 inches. I used this as an example, as I believe you were referring to dietary in a Parkinson patient?....Wish I could assist more.
Exactly my thoughts. If it's not a word, I don't type it, but phenagle it.
Subject: Exactly my thoughts. If it's not a word, I don't type it, but phenagle it.

.
Patient with thoughts of self destruction without s/l suicidality
Subject: Patient with thoughts of self destruction without s/l suicidality


Thank you, both. Janette, sounds highly likely! Much appreciated. Any thoughts on "Me-TOK-a"?
Subject: Thank you, both. Janette, sounds highly likely! Much appreciated. Any thoughts on "Me-TOK-a"? Still


i would not use a comma. the "and" is the connection for two complete thoughts or statements.
Subject: i would not use a comma. the "and" is the connection for two complete thoughts or statements.


you could also correctly use mL rather than cc
Subject: you could also correctly use mL rather than cc

x
Would someone please tell me if I am typing the (e.g) correctly?
Subject: Would someone please tell me if I am typing the (e.g) correctly?


  1. I will see him back in three months to determine his LV systolic function by echocardiogram and then possibly consider other treatment (e.g.,  DC cardioversion and or pacing versus continued pharmacologic therapy.)

I think if I remember correctly it's....nm
Subject: I think if I remember correctly it's....nm


that would be spelled correctly as
Subject: that would be spelled correctly as


anyone know how to correctly type epi SO4? Thanks!
Subject: anyone know how to correctly type epi SO4? Thanks!


Yes you are hearing correctly.
Subject: Yes you are hearing correctly.

Pulsatile lavage is a new procedure for wound debridement. A wandlike device held close to the tissue surface delivers sterile irrigating solution and concurrently suctions . . .


Am I hearing him correctly?
Subject: Am I hearing him correctly?

I just want to make sure I type what he said correctly... would it be phrased that way? "in range of motion instruments machine" Am I hearing him correctly?
How do you type this correctly?
Subject: How do you type this correctly?

The patient is not taking p.o.'s. TIA!
is this punctuated correctly?
Subject: is this punctuated correctly?

Incidentally the patient does have some mild symptoms related to her right ring finger, trigger finger, mild at this time.

The comma after ring finger has me stumped. tia.
it IS right Susan...you're doing it correctly
Subject: it IS right Susan...you're doing it correctly


How to correctly write out creatinine ?
Subject: How to correctly write out creatinine ?

"Creatinine one five"

Creatinine 15 or Creatinine 1.5?
I did google, but evidently not correctly. Thanks so much! nm
Subject: I did google, but evidently not correctly. Thanks so much! nm

nm
how to u correctly write TED stockings? TED/T.E.D./t.e.d.??nm
Subject: how to u correctly write TED stockings? TED/T.E.D./t.e.d.??nm


urothelium, said it correctly in another report. tnx to all.
Subject: urothelium, said it correctly in another report. tnx to all.

nmn

Think you want capsulorrhexis, if I remember correctly. nm
Subject: Think you want capsulorrhexis, if I remember correctly. nm


Is this punctuated correctly? (urology...sm)
Subject: Is this punctuated correctly? (urology...sm)

Pt with condyloma will certainly need..."anesthetic, fulguration, excision and cystoscopy."


Sorry, but I don't know urology well. Not sure if anesthetic fulguation go together or if this is a series of steps! Thank you!


 


 


Hey, Patti, an OP MT here; I think you have the info correctly..sm
Subject: Hey, Patti, an OP MT here; I think you have the info correctly..sm

I would just punctuate a bit differently, like:

Dissection then went to the cephalic aspect of the tumor and a clamp used to delineate it. The tumor was freed of the tissue overlying the innominate vein..... and so on, I think you are doing a good job!
does this sound right and is it punctuated correctly? 2nd ?
Subject: does this sound right and is it punctuated correctly? 2nd ?

The patient is a 42-year-old white female with a torn anterior cruciate ligament, medial meniscus, and anterolateral rotary instability.

Second question is shouldn't this be arthroscopy AND debridement? he doesn't say *and* but that is always how I have heard it. Third question is...is patella tendon graft correct or should it be patellar tendon graft?

I plan on doing an arthroscopy debridement and an anterior cruciate ligament reconstruction using patella tendon graft.

Sorry for all the questions, but he is a speed demon today.

Thank you. do I understand the meaning correctly? sm.
Subject: Thank you. do I understand the meaning correctly? sm.

Bimelic would be more than one of the extremities correct. Monomelic would be only one extremity. It makes sense to me but I don't want to guess.

Thanks so much for your help.
Yes, it's a word and you have it spelled correctly.
Subject: Yes, it's a word and you have it spelled correctly.


didn't post correctly, but I believe it IS pindolol nm
Subject: didn't post correctly, but I believe it IS pindolol nm


Aha, guess it would help to spell correctly when I am researching :-)
Subject: Aha, guess it would help to spell correctly when I am researching :-)

:-)
it was spelled correctly inside the message--sm
Subject: it was spelled correctly inside the message--sm

with the actual definition attached. I am sure she caught that!
HE probably is unaware of how it's correctly written/pronounced. I'd
Subject: HE probably is unaware of how it's correctly written/pronounced. I'd

s
Thought so thanks wish they would dictate the drugs correctly
Subject: Thought so thanks wish they would dictate the drugs correctly


Thanks so much for trying. Positive she is not pronouncing this correctly. She is giving me an eye t
Subject: Thanks so much for trying. Positive she is not pronouncing this correctly. She is giving me an eye twitch... TGIF.


yup, heard it correctly..cobblestoning is a word
Subject: yup, heard it correctly..cobblestoning is a word


you're right GEEZ now I hear it correctly Thanks nm
Subject: you're right GEEZ now I hear it correctly Thanks nm

nm
does this paragraph sound right and is it punctuated correctly
Subject: does this paragraph sound right and is it punctuated correctly

There were findings of a posterior horn tear of the medial meniscus, a small chondral injury of the medial tibial plateau, grade 4 out of 4, chondromalacia of the medial femoral condyle, grade 3 out of 4, chondromalacia patella and trochlea notch of the femur, grade 3 out of 4.

The doctor speeds through this paragraph at 75mph..does it make sense and is the punctuation correct? TIA.
didn't post correctly...should be ൒ vanc" nm ???
Subject: didn't post correctly...should be ൒ vanc" nm ???


leads = Roman numerals if I remember correctly
Subject: leads = Roman numerals if I remember correctly


Doc reviewed the pt's s/l "SSP PET" scan. How to type correctly? nm
Subject: Doc reviewed the pt's s/l "SSP PET" scan. How to type correctly? nm


Jenn, if you give us more context, we can correctly answer this. Thanks. nm
Subject: Jenn, if you give us more context, we can correctly answer this. Thanks. nm

x
Thanks so much! I spelled it correctly in my report, again, brain is fried!
Subject: Thanks so much! I spelled it correctly in my report, again, brain is fried!

nm