any more info? Type of exam, chief complaint, anything at all.
Posted By: Yo on 2008-06-19
In Reply to: worrell - Diane
Subject: any more info? Type of exam, chief complaint, anything at all.
dd
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- worrell - Diane
- any more info? Type of exam, chief complaint, anything at all. - Yo
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chief complaint
Subject: chief complaint
H & P~the doctor says chief complaint:?? sounds like a-pen-ded di-ver (crazy, I know)
The patient awakened that morning with right upper quadrant pain, nausea, fever. The patient has colonic cancer? thanks for any help
Chief Complaint
Subject: Chief Complaint
Chief complaint right foot right shin pain. Fell and went to emergency room and had s/l radiax of her ankle,shin, elbow and wrist on the right side. Nothing about her head. :-(
Can you hear Chief Complaint in there? nm
Subject: Can you hear Chief Complaint in there? nm
It's a chief complaint. Just put it in quotes and you're done.
Subject: It's a chief complaint. Just put it in quotes and you're done.
(like you have it)
A little crazy is okay if it's in quotes, LOL.
:oD
QA ended up changing it to "right" in chief complaint
Subject: QA ended up changing it to "right" in chief complaint
No dx? No chief complaint? No planned tx? Give us a clue here! nm
Subject: No dx? No chief complaint? No planned tx? Give us a clue here! nm
s
Chief complaint: s/l Stiler enalrgement with hyperthyroidism. Help???
Subject: Chief complaint: s/l Stiler enalrgement with hyperthyroidism. Help???
Can you give us some info about the patient, i.e. past history, current complaint, etc?
Subject: Can you give us some info about the patient, i.e. past history, current complaint, etc?
what is the name of a third complaint? S/L thirsory complaint Thanks!
Subject: what is the name of a third complaint? S/L thirsory complaint Thanks!
Are you viewing a joint? Feeling them on an exam? Need more info including a body part! :) nm
.
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
Who specifies no personal info? Type what the dictator says. SM
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.
reply to type of exam look under my LAB from debbie
Subject: reply to type of exam look under my LAB from debbie
Well, it is neurology with a chief
Subject: Well, it is neurology with a chief
complaint of unsteadiness of gait. she has a lot of problems, but he says "past medical history: Medical Illnesses: FBS 110. Would you think that would fall under medical illnesses? I'm pretty sure that is what he is saying, though
Orthopedics: s/l "athetory"-type movements. (Shoulder exam)? Help???
Subject: Orthopedics: s/l "athetory"-type movements. (Shoulder exam)? Help???
Medically it would fit, could you give patient's chief complaints and diagnoses? nm
Subject: Medically it would fit, could you give patient's chief complaints and diagnoses? nm
nm
what is the patient's condition/complaint? nm
Subject: what is the patient's condition/complaint? nm
can you give more? Diagnosis? Complaint?
Subject: can you give more? Diagnosis? Complaint?
x
maybe "tertiary" complaint (nomsg)
Subject: maybe "tertiary" complaint (nomsg)
x
Give us the line and context it is used, what is the complaint.
Subject: Give us the line and context it is used, what is the complaint.
Word help s/l glener nerve complaint
Subject: Word help s/l glener nerve complaint
He has not had numbness or tingling in his hands, trouble with walking, s/l glener nerve complaint
There are no palpable cords or calf tenderness, despite the patient’s complaint of diffuse body ache
Subject: There are no palpable cords or calf tenderness, despite the patient’s complaint of diffuse body ache
Throat exam is normal, as were the rest of her neck, face, and skull exam.
Subject: Throat exam is normal, as were the rest of her neck, face, and skull exam.
Eye exam: s/l "sub-lamp" exam shows left side has multiple small punctations in the cornea.(t
Subject: Eye exam: s/l "sub-lamp" exam shows left side has multiple small punctations in the cornea.(thanks)
Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
Subject: Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
What kind of doc is doing the exam? And where in the exam is this test mentioned? nm
Subject: What kind of doc is doing the exam? And where in the exam is this test mentioned? nm
s
Question about eye exam...when everting lids on eye exam (sm)
Subject: Question about eye exam...when everting lids on eye exam (sm)
It is EVERT, not AVERT, right? I have always typed it with an E but I have a PA who keeps insisting it is A. I always thought Avert applied to gaze, as if to look away. Just want to make sure everting the eyelid is the right term. TIA.
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
which is preferred ~ diabetes mellitus type II or type 2?
Subject: which is preferred ~ diabetes mellitus type II or type 2?
I get confused, how do you type out grade, class, type SM
Subject: I get confused, how do you type out grade, class, type SM
I forget which ones use Roman and which do not. TIA
When doctor says tib-fib, do you type it like that or do you type tibiofibular? Thanks
.
Siewart type I or Siewert type I
Subject: Siewart type I or Siewert type I
When I google it, I'm finding both. Cannot locate it in a Stedman's book. Doctor spells with "a" but you can't always go by the spellings!
How do I type this particular type of dialysis bath? sm
Subject: How do I type this particular type of dialysis bath? sm
Doc is an ESL and unclear, but it s/l he is saying "...using a 3 K 21/2 bath." I have never had this in a report and after googling, am still as clueless as I was. I cannot find it in AAMT, either. Any help would be appreciated. Thank you!
acromion process - type 2 or type II
Subject: acromion process - type 2 or type II
Could it be hollowing-type or hollow-end-type? - nm
Subject: Could it be hollowing-type or hollow-end-type? - nm
xx
how to type out Type I Aortic aneurysm
Subject: how to type out Type I Aortic aneurysm
Would you use a roman numeral for Type I Aortic aneurysm or use Type one or type 1 ... I am thinking it is Type I but I am unsure. I am new to this all. Thanks for any help.
I would type it under PLAN and type what is dictated.
Subject: I would type it under PLAN and type what is dictated.
I have had that happen to me before, and I was told by QA to not move things around in the report, maybe that is the same for you, but if I were typing this report, I would type it in the order as is dictated, even if that means typing it under the heading PLAN. Also, his vitals were probably taken at the end of the exam as they were repeated, so it would make sense to type them again under that heading. Hope that helps!
Which is correct? self-breast exam or breast self-exam (nm)
Subject: Which is correct? self-breast exam or breast self-exam (nm)
xx
Type II diabetes vs. Type 2....sm
Still running into confusion about this....which is it? If Type 2, was this a medical community change accepted by all?
Could it be pincer-type and cam-type?
Subject: Could it be pincer-type and cam-type?
x
Type 2 DM or type II DM, which is correct? nm
Subject: Type 2 DM or type II DM, which is correct? nm
what type of dictation do you type?
Subject: what type of dictation do you type?
It might help to know the specialty. I am finding a lithiasis, but I don't think it would relate to gonorrhea, are you sure it is gonorrhea?
how to type a blood type
Subject: how to type a blood type
simple question but how is a blood type transcribed .. such as 0+ .. is there a space between the 0 and + or is the word positive typed out? Thanks for your help.
ONCOtype, ONCO type, ONCO Type, found all three...
Subject: ONCOtype, ONCO type, ONCO Type, found all three...
nm
MRI of the C-spine - which is correct Modic type II changes or Modic type 2 changes.....nm
Subject: MRI of the C-spine - which is correct Modic type II changes or Modic type 2 changes.....nm
pincer-type nail or pincher-type nail? nm
Subject: pincer-type nail or pincher-type nail? nm
more info please :)
Subject: more info please :)
nm
Just info
Subject: Just info
This can be very crippling disease. I have a friend who is only 33 and cannot even scratch her own nose. She cannot turn over in bed or do anything for herself. It is a progressive illness. When she was little, she could walk and do everything a normal child could and by the time she was a teenager she was in a wheelchair. Now she is completely disabled.
Thanks for all the info
Subject: Thanks for all the info
I came close to leaving a big blank for QA. thanks again for the lesson.
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