assessment ?
Posted By: Tracey on 2008-02-15
In Reply to:
Subject: assessment ?
Patient had an s/l EIP - EPL transfer.
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Assessment
Subject: Assessment
ASSESSMENT: Family history of AAA. Will proceed with -- s/l "root" ----- to evaluate.
Anyone have any idea what this is?? I'm drawing a blank.
TY!!
Help with assessment
Subject: Help with assessment
Hypertension with s/l "realciaporosis"...??
Any ideas??
TIA 
in the assessment i would, otherwise no
Subject: in the assessment i would, otherwise no
Assessment ?
Subject: Assessment ?
Assessment ?
Subject: Assessment ?
Can you have an abbreviation like URI in an assessment? Thx. Tina
Assessment
Subject: Assessment
Thank you for the assessment info!!
CAGE assessment?
Subject: CAGE assessment?
CAGE Assessment (Alcohol Abuse)
Powered by:. CAGE Assessment (Alcohol Abuse). For most people who drink, alcohol
is a pleasant addition to eating and to other social activities. ...
https://www.merck.healthinkonline.com/ merckTools/AssessMerckSourceCAGE.asp - 19k - Cached - Similar pages
screening questions - CAGE assessment
Aquarius - UK Midlands charity providing advice and counselling on alcohol and
drugs problems.
www.aquarius.org.uk/cage.htm - 14k - Cached - Similar pages
Livingston County Council Alcohol & Substance Abuse - Assessment
Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan
1. Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago. I asked him to repeat it, but he forgot. We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly. He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
It was not a test. It was the assessment.
Subject: It was not a test. It was the assessment.
nm
assessment&plan help!
Subject: assessment&plan help!
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
- Bilaterally arm numbness.
- Nausea.
- Health maintenance recommendations.
PLAN:
- Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion. She will be referred for MRI with cervical spine. Patient may need EMG to further access her numbness.
- Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn. She does have chronic nausea and this may be a sign of stomach reflux. She will be tried on Nexium 40 mg one q.d. Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night. We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism. ___ problem health maintenance and in regards to increase her exercise and changing her diet. Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram. When she follows up to see me we will discuss potential options for colon screening. Patient is to follow-up with me in approximately 1 month time.
assessment and plan
Subject: assessment and plan
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not? TIA!
Should EKG be expanded in Assessment?
Subject: Should EKG be expanded in Assessment?
ASSESSMENT: Abnormal EKG.
question about assessment
Subject: question about assessment
Doc states CABG and mitral valve repair. He clearly states this together. Can this be listed as one assessment? Or should mitral valve repair be next number??
pulmonary assessment
Subject: pulmonary assessment
admitted for elective mediastinoscopy, s/l radio-gram-coscopy?? and left bronchotomy.
Assessment: Vaginitis DX. I never heard of DX?? thanks
Subject: Assessment: Vaginitis DX. I never heard of DX?? thanks
Under assessment: UNCOMPELLING EMG results
Subject: Under assessment: UNCOMPELLING EMG results
Is uncompelling a word?
Or is it noncompelling?
Thanks!
Assessment: Dry skin (s/l ictiosis).
Subject: Assessment: Dry skin (s/l ictiosis).
:-)
Geriatric Assessment Unit
Subject: Geriatric Assessment Unit
.
Oh...assessment is diagnosis..so I would type it out nm
Subject: Oh...assessment is diagnosis..so I would type it out nm
xx
"HO" assessment (alcoholism)
Subject: "HO" assessment (alcoholism)
Has anybody ever heard "EtOH" pronounced as "aitch oh"? Or know what "HO assessment" could mean in relation to alcohol treatment?
"Patient was not eligible for HO assessment."
Thank you!
s/l topo or tolpol for fetal assessment
Subject: s/l topo or tolpol for fetal assessment
Hi! Need help as soon as possible. Typing history and physical for admission of a woman in labor. Here is what is dicated:
Fetal heart rate tracing is in the 140s and reassuring with good variability, accelerations, and no decelerations. (s/l topo or tolpol) is minimal if at all.
Thanks in advance!!
It is Mallampati. A classification used in ariway assessment.
Subject: It is Mallampati. A classification used in ariway assessment.
The number would be Class IV
Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
Subject: Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
nm
Assessment: s/l maseno fracture right ankle. nm
Subject: Assessment: s/l maseno fracture right ankle. nm
CIWA-Clinical Institute Withdrawal Assessment nm
Subject: CIWA-Clinical Institute Withdrawal Assessment nm
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though.
He goes right into the Assessment of elevate PSA and bilat. iguin. hernia
Subject: He goes right into the Assessment of elevate PSA and bilat. iguin. hernia
CIWA-Clinical Institute Withdrawal Assessment
Subject: CIWA-Clinical Institute Withdrawal Assessment
score
Think you need CIWA - Clinical Institute Withdrawal Assessment nm
Subject: Think you need CIWA - Clinical Institute Withdrawal Assessment nm
x
clinical institute withdrawal assessment (CIWA) protocol. nm
Subject: clinical institute withdrawal assessment (CIWA) protocol. nm
in assessment says Esoteric ??? failure, blunt chest trauma
Subject: in assessment says Esoteric ??? failure, blunt chest trauma
CIWAClinical Institute Withdrawal Assessment for Alcohol (CIWA) nm
Subject: CIWAClinical Institute Withdrawal Assessment for Alcohol (CIWA) nm
CIWA level - Clinical Institute Withdrawal Assessment
Subject: CIWA level - Clinical Institute Withdrawal Assessment
CIWA score (Clinical Institute Withdrawal Assessment) NM
Subject: CIWA score (Clinical Institute Withdrawal Assessment) NM
Gail Model Risk Assessment Tool (GMRAT) for breast CA. nm
Subject: Gail Model Risk Assessment Tool (GMRAT) for breast CA. nm
information for
Pt had itching she treated with OTC Monistat. Assessment s/l vagini ovitis symptoms.
Subject: Pt had itching she treated with OTC Monistat. Assessment s/l vagini ovitis symptoms.
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