doctor didn't dictate mg????
Posted By: Am on 2009-02-19
In Reply to:
Subject: doctor didn't dictate mg????
The patient was given aminophylline, Lanoxin 0.25, Lasix 40 mg, Cardizem.
okay here the doctor fails to dictate mg? according to 'textbook rules' do I add this or not?
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doc didn't dictate that....her brain was thinking that...
Subject: doc didn't dictate that....her brain was thinking that...
nm
wow thanks, this doctor definitely didn't sound like a "z". thanks again
Subject: wow thanks, this doctor definitely didn't sound like a "z". thanks again
A few Meds - Coban or Cobain, s/l Slizabell (doctor didn't even know)
Subject: A few Meds - Coban or Cobain, s/l Slizabell (doctor didn't even know)
thanks
I did Google it, but I didn't know it was a hearing test it didn't pop up. Sorry to bother you
Subject: I did Google it, but I didn't know it was a hearing test it didn't pop up. Sorry to bother you.
No, I didn't mean that as a slam that you didn't research!!!
Subject: No, I didn't mean that as a slam that you didn't research!!!
I just meant that it's checked and verified for you. Shitzoo showed up on Google, too. LOL
You should dictate what the doc says.
Subject: You should dictate what the doc says.
If he is wrong, that's his problem. You can't just go changing what he says unless you have free reign on your account.
Drs get what they dictate - some of us only do..S/M
Subject: Drs get what they dictate - some of us only do..S/M
brachioplexus, brachioplexopathy - what they say is what they get....client profile RULES!
How does he dictate it? Is he actually - sm
Subject: How does he dictate it? Is he actually - sm
Is he saying "CBC, MSP, and stool" because stool is not a test so just wondering if it could be the name of a stool test. If you state just how the whole sentence is dictated, it may help us figure it out for ya.
I had a doc used to dictate that
Subject: I had a doc used to dictate that
Good says it stands for keep-open-vein. So, it should fit, and it also is all CAPs. 
Usually if they dictate Seldinger...
Subject: Usually if they dictate Seldinger...
they will say "via Seldinger, or Seldinger technique." I don't believe they would do this en route either. Are you sure you are hearing "sandwich?" I have been transcribing ER reports for years and I have never heard this term used. Anyway, I would not guess on this one. IMO, it is better to leave it blank and have QA inform you later so you can keep it on file  .
Yes, that was how I was taught and most always they dictate cc nm
Subject: Yes, that was how I was taught and most always they dictate cc nm
nm
welcome; got it from my docs that dictate it as i never could figure them all out either, lol. nm
;
Sorry, but I have had them dictate brain or beta.
Subject: Sorry, but I have had them dictate brain or beta.
nm
Account specifics would dictate whether you sm
Subject: Account specifics would dictate whether you sm
write it out or abbreviate. The abbreviation for beats per minute is bpm. Ask your QA person for approved abbreviations for this account (accounts will differ sometimes which can make us crazy).
Did she dictate the colon after "murmur?" nm
Subject: Did she dictate the colon after "murmur?" nm
x
no matter what they dictate, they are wrong...nm
Subject: no matter what they dictate, they are wrong...nm
LOL..the way these docs dictate anymore
Subject: LOL..the way these docs dictate anymore
who knows!! Something like that just check your aspirin bottle. Good luck!!
Lordy, when they dictate commas it is just sm
Subject: Lordy, when they dictate commas it is just sm
like a poke in the eye to me!!! Brings me to a screeching halt. I just tend to ignore them, in a report, especially if it is a resident. I do puncturate letters and memos, but half the commas I see people use on this board and other boards are totally not necessary. Just call me
anti-comma!!!!!
If you dictate the full sentence I could probably help you figure it out. nm
Subject: If you dictate the full sentence I could probably help you figure it out. nm
Thanks for finding that. I just had doc today dictate this...hmmmm
Subject: Thanks for finding that. I just had doc today dictate this...hmmmm
Thought so thanks wish they would dictate the drugs correctly
Subject: Thought so thanks wish they would dictate the drugs correctly
or may be mistakenly thinking of their pet's food as they dictate?
Subject: or may be mistakenly thinking of their pet's food as they dictate?
wrong - they ALL dictate decubiti...no such word
Subject: wrong - they ALL dictate decubiti...no such word
did he dictate the point, or did he say 1 5, to make sure you did not hear 50
Subject: did he dictate the point, or did he say 1 5, to make sure you did not hear 50
nm
Thanks again...tried that but didn't get anything because I didn't know how to spell it. (nm)
Subject: Thanks again...tried that but didn't get anything because I didn't know how to spell it. (nm)
x
That's what I mean by "ask your QA!" Account specifics dictate style, sm
Subject: That's what I mean by "ask your QA!" Account specifics dictate style, sm
but the AAMT BOS dictates what is correct for the industry, getting its information from sources such as the Chicago Manual of Style, the American Medical Association book of style (which I own), etc. As the poster below states, Joint Commission goes by BOS and does not like "same" or abbreviations for diagnoses, impressions, op titles, etc. They will randomly choose patient charts and go through them to check things like this! It's the Joint Commission which recommends or removes hospital accreditations--a very powerful entity.
So, ask your QA what the account wants. If they want "same," give them "same." For other accounts, do it the correct way.
Derm docs often dictate "Allergy to CARBO mix" - sm
Subject: Derm docs often dictate "Allergy to CARBO mix" - sm
I don't know what the full word is, but this validates your hearing the partial "carbo"
Long shot, but often dictate myocardial ischemia. nm
Subject: Long shot, but often dictate myocardial ischemia. nm
xx
Macrobid (nitrofurantoin) is commonly used, maybe doc stumbling on whether to dictate brand name or
Subject: Macrobid (nitrofurantoin) is commonly used, maybe doc stumbling on whether to dictate brand name or generic?
there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
Subject: there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
if that's it? This is usually dictated when they don't want to list the entire medication list so refer to the MAR that is in the chart.
Pupils equally reactive to light, they do not always dictate the whole exam abbreviation, they ..sm
Subject: Pupils equally reactive to light, they do not always dictate the whole exam abbreviation, they ..sm
do not always examine all aspects on PE. Hope this helps!
Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the ti
Subject: Don't be confused by dift opinions. Blank if unsure. However, docs dictate one-teens all the time.
Didn't think of that! Thanks!! nm
Subject: Didn't think of that! Thanks!! nm
x
No, you didn't. nm
Subject: No, you didn't. nm
x
Oh! Thank you - wonder why this didn't
Subject: Oh! Thank you - wonder why this didn't
come up on my abbreviation website!
You know, I didn't think of that....sm
Subject: You know, I didn't think of that....sm
I am going to listen again and I bet that is it. Thank you so much!
I didn't see that, thank you!
Subject: I didn't see that, thank you!
x
Thank you. I didn't think of that.
Subject: Thank you. I didn't think of that.
You could be right.
I didn't think it could come
Subject: I didn't think it could come
in 1200 mg. I left a discrepancy marker in 1 of my reports for this, and the QA took out my marker and put in Dilaudid 1200 mg like the dictator said. Go figure.
I didn't think of that - this could be it! Thanks. nm
Subject: I didn't think of that - this could be it! Thanks. nm
x
Okay, just didn't think
Subject: Okay, just didn't think
she lie herself down sounded right, so wanted to be sure. Thanks!
I didn't have the
Subject: I didn't have the
first one, but I use 911 all the time for everything! I've done a few OP reports, but I have 34 to do today and I am on my 5th one after 2 hours of working! Thanks for the help!
didn't think so! - nm
Subject: didn't think so! - nm
Didn't you ever get this?
Subject: Didn't you ever get this?
The reason it didn't occur to people was that you didn't give enough information to let them know it was part of the physical exam, either HEENT or neuro exam. When clues are provided, people are happy to help. Otherwise it's a lot of effort on their part and none on the person asking the question.
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oh wow i didn't see that thank you!
Subject: oh wow i didn't see that thank you!
She didn't
Subject: She didn't
you must not have read her post, which states:
"I agree it looks weird, but "appropriate for gestational age" is a compound modifier for "infant." Weird or not, that's the way it is. My opinion, if the correct way looks too "weird" for you and you don't mind getting pinged by QA, then use no hyphens at all because "gestational- age" definitely should not be hyphenated."
Another option, if this is not a verbatim account, would be to re-cast the sentence.
Sorry. I didn't know that. nm
Subject: Sorry. I didn't know that. nm
Didn't mean to
Subject: Didn't mean to
add past tense. Sorry... :-)
You didn't think it may have
Subject: You didn't think it may have
been BioCleanse?? :-)
I didn't know you
Subject: I didn't know you
could drink marijuana...What will they think of next???
I didn't say
Subject: I didn't say
IBS "disease." You did..
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