how about typing Past Medical History heading and then typing what he says under the heading nm

• Heading? - Kristi
  • A doctor can put in any heading they - sm
  • how about typing Past Medical History heading and then typing what he says under the heading nm - NYMT2

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dictator says: Past medical history for hypertension. Past surgical history is arthroscopy of his right knee. Allergies are to Demerol and Penicillin. Do I put Headings over each one and keep the exact dictation like this:  PAST MEDICAL HISTORY (type under this title) Past medical history for hypertension OR just Hypertension. Other part of my question.  ROS subheadings: dictator says this: Cardiovascular has a history of hypertension.  do I need to put a colon in there and cap the Has? or leave as I have typed in bold? Do I add a subheading of GI/GU: for this sentence - No GI/GU problems. Does this sentence also need colon?  Musculoskeletal I stated in the HPI. No neurological or hematological discorders.  Thanks for any help, sorry if these seem like dumb questions...but I really need the help.

Under history of present illness he has that the patient has a history of IV drug abuse.

Past medical history: IODINE ALLERGY WITH SHORTNESS OF BREATH AND HIVES FOLLOWING IV SPREE THREE YEARS PTA.

Could that be what he's saying? Thanks.

Surgeries: Small bowel obstruction, THA/BA for cholecystectomy.

I'm not sure if he said BA or BA with another letter on the end. Help! Thanks.

Under past medical history he states "Basal cell **and blue** carcinoma.

My apologies if this is something simple, but this is what it sounds like and I am not finding anything to point me in the right direction. Thanks!

CABG 1998 and s/l CVAA SPVD status post right lower extremity amputation and hypertension.

Thank you

Deborah

listed is s/l Berjay's disease.

I've Googled every spelling I can think of and have come up blank 

Under past medical history, dictator is saying s/l ben r r ma gene.  Or banner arma gene.  ??? 

Patient also has hypertension, dyslipidemia, asymptomatic stroke, sleep apnea, renal insufficiency.  Any ideas?

how do you write that out?

atrial fibrillation, afib? 

Too early for me right now.

s/l "dis-turds" versus anemia.  The doc is is seriously mumbling but I think he says something like this.

Some say Cardiac:   S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.

Okay to add headings on OP report.  MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....

Thanks.

put inguinal hernia in a PE?  Would it be abdomen?

TIA

I would put under EKG alone as

This is for a psych. consult.  After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.

I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records.  Past Medical History, yes, but not the other.  Any ideas?

Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".

Thanks

Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?

s/l "the PICC was created" or "the tic was created"

Angie

He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.

What would be asymmetrical here?