i would say Examination and Evaluation needs to be put as a heading.
Posted By: mt-123 on 2008-03-17
In Reply to: Help with sentence. This is doc's treatment/plan: sm - Jan
Subject: i would say Examination and Evaluation needs to be put as a heading.
just my thoughts.
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Sorry, this should have been under heading Physical Examination.
Subject: Sorry, this should have been under heading Physical Examination.
Abdominal examination - s/l no jaboya by examination? TIA
Subject: Abdominal examination - s/l no jaboya by examination? TIA
how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
GAU evaluation
Subject: GAU evaluation
Does anyone know what this pertains to? I do not find anything in my Stedman's reference that would shed light on it. The patient is 51 years old and it is a very short dictation with little detail.
evaluation and treatment?
Subject: evaluation and treatment?
x
Evaluation of right shoulder . . .
Subject: Evaluation of right shoulder . . .
Evaluation of his right shoulder shows he does have some atrophy in his 'p_____ disfaucet'.
I know that is not right, but that I was I get from his garble and what sounds like him eating the recorder. LOL
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s/l fornik evaluation (sm)
Subject: s/l fornik evaluation (sm)
The patient had been on aspirin at the time of his stroke. He was changed to Plavix. He may be considered for __________ evaluation in the future.
This doctor flies through the dictation at warp speed, but the closest I can hear is "fornik."
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Maybe "eval" for evaluation???
Subject: Maybe "eval" for evaluation???
x
Re-evaluation or Reevaluation?
Subject: Re-evaluation or Reevaluation?
Any idea whether this word has a hyphen or not?
Thank you
Could the doc just be stumbling on GU evaluation? Sorry not more help Nm
Subject: Could the doc just be stumbling on GU evaluation? Sorry not more help Nm
nm
maybe for "a VATS" evaluation ??
Subject: maybe for "a VATS" evaluation ??
s/l "Osfinder" evaluation of cervix
Preoperative diagnosis is:
RECURRENT HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION FOLLOWING CONE BIOPSY AND CERVICAL STENOSIS PENDING PATHOLOGY.
Procedure is:
EXAMINATION UNDER ANESTHESIA, **OSFINDER** EVALUATION AND DILATATION OF THE CERVIX.
vVery muffled, but "--finder" seems clear (??).
sentence..Returned for re-evaluation of her...
Subject: sentence..Returned for re-evaluation of her...
blood pressure. She is on clathylone, verapamil 240 b.i.d., Mevacor 20 b.i.d., Prilosec, Flexeril, Mataglip and atenolol 25 a day.
She has had restriction of activity secondary to her let shoulder surgery and her right hip arthalgias.
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evaluation for renal colic
Subject: evaluation for renal colic
s/l BNP? Doc is talking about her evaluation for renal colic the def for this abbrevation does not seem to match this evaluation. Could it be something different?
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Subject: Evaluation for possibility of lymphoma
His peripheral blood lymphocyte analysis revealed no s/l coronal populations.
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Subject: Actually, can't get VATS out of it....:P...any ideas? on E Vas or E vus evaluation?
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Subject: Psych evaluation drug question
Just going over his general psychiatric history and what drugs he has tried:
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TIA!!
Here is the paragraph for the s/l line infection evaluation..
Subject: Here is the paragraph for the s/l line infection evaluation..
Patient here today for a post-op s/l line infection evaluation. She has been doing daily wet to dry dressing changes and today the wound breadown area is less than a cm across and with probing with a Q-tip will not extend any greater than 2 cm in the area. I do not think that this continues to require any packing. I have recommended that she just keep gauze over the area for the drainage. thank you
fiberoptic endoscopic evaluation of swallowing ?
Subject: fiberoptic endoscopic evaluation of swallowing ?
DME durable medical equipment evaluation?
Subject: DME durable medical equipment evaluation?
Consider KRAS and s/l ?brath? mutations evaluation.
Subject: Consider KRAS and s/l ?brath? mutations evaluation.
NM
Kohlman Evaluation of Living Skills (KELS) nm:)
nm
Absolutely; Arch Range of Motion and Evaluation.
Subject: Absolutely; Arch Range of Motion and Evaluation.
examination ?
Subject: examination ?
leg examination
Subject: leg examination
s/l Omin sign is negative.
any idea? The patient has calf muscle tendernes.
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
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Under what heading would you SM
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
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EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
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Heading?
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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.
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Referred to interventional pulmonologist for potential "EE VAS" evaluation.
Subject: Referred to interventional pulmonologist for potential "EE VAS" evaluation.
Pt with subcarinal mass on CT.
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Subject: right knee examination...pls s/m. Thank you!!!
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tissue for ERA, PRA, DNA, poly harvested in one slide.
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under HEENT examination the doctor states -
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This is in the physical examination. Thanx for trying
Subject: This is in the physical examination. Thanx for trying
TYPE OF EXAMINATION
Subject: TYPE OF EXAMINATION
I was wondering if anyone has heard of SIMM CARD EXAM positive for BV. I have searched the Internet and am not able to find this term. Thanks a bunch
Physical examination... sm
Subject: Physical examination... sm
Examination of female patient.
Musculoskeletal: No (s/l) keps, pains, or pedal edema...
Genitourinary: No (s/l) [cussforteeballing or maybe cusp or teeballing], or area tenderness.
Thanks in advance!
EUA--examination under anesthesia?
Subject: EUA--examination under anesthesia?
Physical Examination
Subject: Physical Examination
Happy Monday everyone! Hope you all had a great weekend! I'm doing a report and wondering if any of you can point me in the right direction!
"There is good capillary refill and s/l preson to cultures over both lower extremities." Any thoughts? Any good physical examination websites?
s/l physical examination
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examination? catheterization? nm
Subject: examination? catheterization? nm
.
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Subject: neurologic examination
sounds like doc is saying "neurologic examination higher critical function", but could she be saying "neurologic examination hilar cortical function"?
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Subject: Exam/Examination
Is exam considered a complete word or just an abbreviation of examination?
No, this is a knee examination. :( nm
Subject: No, this is a knee examination. :( nm
nm
MVA accident examination- sm
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Subject: Evaluation of her wrist shows that she has normal s/l pee-un-okee_____ with the DRUJ in 0 supination
xx
OB longshot..here today for a post-op s/l wine infection evaluation..if you need more info let me
Subject: OB longshot..here today for a post-op s/l wine infection evaluation..if you need more info let me
know and i will write out the whole sentence. thanks
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Subject: possibly E&M? =(HCFA) documentation guidelines for Evaluation and Management (E and M) Services
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Oops, used same heading, need help
Subject: Oops, used same heading, need help
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