for what type of pain? what is the report about?
Posted By: me2 on 2007-06-01
In Reply to: s/l Rubier's pain rating ?? - bizzyfingers
Subject: for what type of pain? what is the report about?
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what type of report is it?
Subject: what type of report is it?
is this an op report or H&P or what?
Usually depends on the type of report
Subject: Usually depends on the type of report
While account specifics vary from hospital to hospital, I don't think I've had a hospital with an H&P that didn't require that you separate out the headings; discharge summaries, on the other hand, are usually allowed to be in paragraph form, and consults are a toss-up. Clinic/office notes are totally a matter of account specifics. When you get into specialty clinics, they sometimes break it down even further; i.e., an ENT doctor may separate out HEAD: EYES: EARS:, etc., and a neurologist may do MENTAL STATUS: CRANIAL NERVES: STRENGTH: REFLEXES, etc. However, in most cases, if the doctor uses headings in an exam for some of the systems/body parts, you usually are to use the appropriate ones for all; as noted, though, that is dependent on account specifics.
TMGE type pain?
Subject: TMGE type pain?
Dr. Says: She states that she was diagnosed with severe TMJ and that her ear had looked fine, and she also saw a doctor for an ENT consult. He agreed that he felt this was a jaw issue.
ASSESSMENT: TMGE type pain, also some spasm in her left neck. It seems like the sternocleidomastoid muscle area. So, it does seem like TMJ syndrome. (What is TMGE?) 
I type for pain management
Subject: I type for pain management
and always type pain as 5/10. Nothing has ever been said, so I don't know if it's right or wrong.
Anesthesia-type pain
Subject: Anesthesia-type pain
Doctor's say this all the time. It means a numbing-type of pain.
Got a body part? Report type? Something before and after this???nm
Subject: Got a body part? Report type? Something before and after this???nm
s
text before? after? context? type of report? help us help you... nm
Subject: text before? after? context? type of report? help us help you... nm
a type of fracture on a radiology report
Subject: a type of fracture on a radiology report
(Am new to radiology) Pertaining to right elbow fracture: S/L "desalergeeze" fracture. I have been trying to hear "distal ........ fracture" but it sounds like the above. Thanks so much.
What comes before or after this? Where in the dictation is this located? Type of report? nm
Subject: What comes before or after this? Where in the dictation is this located? Type of report? nm
s
How would I type a math equation in a report?
Subject: How would I type a math equation in a report?
Dictator said client answer 100 minus 7 as 93 after much calculation. Should I use the minus and equal signs? Thanks in advance....
how do you type pain free? one or two words?
Subject: how do you type pain free? one or two words?
How do you type acute oncronic pain? nm
Subject: How do you type acute oncronic pain? nm
TIA
I would say nerve regeneration-type pain.
Subject: I would say nerve regeneration-type pain.
I am not sure what type of report you are doing, but could it be amantadine and Zetia for the 2 meds
Subject: I am not sure what type of report you are doing, but could it be amantadine and Zetia for the 2 meds ?
possibly occult sciatic pain ( pain hidden/concealed/not manifest) ? nm
Subject: possibly occult sciatic pain ( pain hidden/concealed/not manifest) ? nm
if it's in the spine, it could be "discogenic" pain versus "facet"-related pain
Subject: if it's in the spine, it could be "discogenic" pain versus "facet"-related pain
could be TKA-total knee amputation. pain could be "ghost" pain --nm
Subject: could be TKA-total knee amputation. pain could be "ghost" pain --nm
///
Drug name - s/l amarek, for back pain and neck pain
Subject: Drug name - s/l amarek, for back pain and neck pain
Any ideas? Thanks!
shoulder pain and knee pain
Subject: shoulder pain and knee pain
Doctor says, "he denies any neck pain or s/l ridicular symptomatology into the upper extremity.
nEck pain and back pain
Subject: nEck pain and back pain
what a day!
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
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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!
EKG report
Subject: EKG report
"No weeshnoblomotion abnormalities are identified." What is that word?
thanks everyone. One more report and then I am going to bed.
Subject: thanks everyone. One more report and then I am going to bed.
nothing more to add about the report unless
Subject: nothing more to add about the report unless
the patient had an implanted pacemaker which is not eluded to here. Just a note, adenosine is not capitalized except to start a sentence.
Maybe you will hear something back.
d~
Sorry, same report...
Subject: Sorry, same report...
"CPK and _______ were negative" s/l intraconals??
Still on the pulmonologist's report...
EEG report
Subject: EEG report
Anyone ever heard of an EEG performed on a Nikon Codon machine? Thanks.
just sent the report on.........nm
Subject: just sent the report on.........nm
x
op report sm
Subject: op report sm
What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.
You don't say where in the report -- sm
Subject: You don't say where in the report -- sm
this is given, or any other context, so I have to wonder if this isn't a problem list perhaps giving more than one diagnosis/problem here (as in (1) portosystemic shunt and (2) nephrolithiasis)...
Just a thought
ENT report - sm
Subject: ENT report - sm
Does include sinus surgeries, Caldwel-Luc surgery. Is also on Flonase. Patient is actually here regarding Grave's disease. I'm wondering if this is Relpax D, but I'm not able to verify that as a drug. Any suggestions?
ENT OP report help, please...
Subject: ENT OP report help, please...
Vocal cord lesion biopsy -
Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.
Specimen was sent -s/l informal- and for pathology.
TIA!
OP report
Subject: OP report
OP report, lumbar spine
Next, fluoroscopy was used to place new screws at the L2-3 segment. Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis
He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!
op report help please sm...
Subject: op report help please sm...
FINDINGS: Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle. The patient did experience some concordant L5 symptoms on the right side during the injection. Vital signs remained stable throughout.
OP Report
Subject: OP Report
Hi all! I am doing an OP for a lumbar spine surgeon, but this is just for an I&D. He says the area was probed with "sucker tips" and was found to be subfascial. I am not too comfortable with what I am finding online for this. Has anyone heard this before? Thanks!
OP report help, please
Subject: OP report help, please
Patient was premedicated with intravenous s/l Benadryl.
Would that be right?
report does not say .. but says she is on BC
Subject: report does not say .. but says she is on BC
help with op report
Subject: help with op report
I never do op notes! The sentence reads:
The S/L RAFFAY between the anterior and middle deltoids was then opened. TIA!
Doing EMG report sm
Subject: Doing EMG report sm
The patient has focal severe slowing primarily in sensory fibers in the right upper extremity, on multiple restimulation unable to elicit a response to both s/l "Palmar 8" studies.
I can't find this anywhere. Anybody have any ideas? Thanks!
I wish I could see the report, but
Subject: I wish I could see the report, but
could she be saying communication, as in an opening has formed between 2 sinuses or something?
It is so frustrating to be given only a tidbit of a report instead of being able to puzzle it out from what is going on with the patient.
Thanks, but as I'm into the report it
Subject: Thanks, but as I'm into the report it
sounds like this is some weird wording for microscopic blood.
I've done thousands of endoscopy reports and GI consults, but I can't think why he'd say "affobiddy positive stool" instead of something about occult blood or microscopic blood.
ER report. Sm please
Subject: ER report. Sm please
The patient has a 4 mm calcification on the pelvis on the right which may represent a s/l flevolith, thus a right ureteral calculus could not be entirely occluded.
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