more on psych reports
Posted By: MT on 2009-02-20
In Reply to:
Subject: more on psych reports
When there are multiple items under an AXIS, should #1 start two spaces after AXIS I, or hit return and start #1 at the left margin?
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
psych reports
Subject: psych reports
Just wondering if GAF on psych diagnosis should be expanded to Global Assessment of Functioning? Or just GAF
I work on psych reports
Subject: I work on psych reports
we capitalize Verbal, Performance, and Full Scale IQ where I work. We have all our resulting scores listed in a table. I hope this helps. Where are you getting all the psych work from?
Yes, it is a word used a lot in psych reports nm
Subject: Yes, it is a word used a lot in psych reports nm
xx
Hate psych, too! Only had to do a few reports in my entire career. Boring stuff! nm
Subject: Hate psych, too! Only had to do a few reports in my entire career. Boring stuff! nm
s
s/l *naw-vin* 10 mg bid (not Novolin or Darvon) - psych pt but may not be psych med - TIA - nm
Subject: s/l *naw-vin* 10 mg bid (not Novolin or Darvon) - psych pt but may not be psych med - TIA - nm
x
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Thank you! (New at these Op Reports!!)
Subject: Thank you! (New at these Op Reports!!)
Reports. (SM)
Subject: Reports. (SM)
The posts containing the reports have been removed and the poster was notified about not posting such information in the future.
Please feel free to contact the administrator (admin@mtstars.com) or myself (goldbird@mtstars.com) if you have any questions.
Your comments and postings are very much welcome here.
Let me know if I can help you,
Goldbird
Reports
Subject: Reports
I only got help for 2 reports, and the people that helped me wanted to help me.
No one was forced and I greatly appreciate their help. I just needed help in some areas that I was having some trouble in that is all.
You and Milton Red Stapler have a nice day.
and in my reports...I put....sm
Subject: and in my reports...I put....sm
*in regard to*, not *in regards to*....and as far as *alot* goes, I am used to my word program separating that out as a lot, and since this message board program does not do that, oh well....get off it already. sheesh. nitpickers!
new to op reports
Subject: new to op reports
I am new to op reports and looking for any good reference sites to refer to when needing help. My ops mostly consist of General surgery, orthopedic, ENT, ophthalmology, gyn and plastic surgery.
Any guidance would be appreciated. I have a M&S Equipment words book and an ortho book. Would like some good websites.
Thanks in advance
fractions in reports
What is acceptable, 1/4 or one-fourth? Thanks.
Newbie's reports
Subject: Newbie's reports
The area in which you most need help is in how to decide what is ethical. The moderator herself does not allow such reports to be posted here. You should have known better. Now you do.
sample reports
Subject: sample reports
MT daily has sample reports, I need a C-section. Know where I can get one. Thanks in advance.
Psychiatric reports.
Subject: Psychiatric reports.
I have a question in regards to psychiatric evaluations. Would diagnosis or diagnoses be used when typing out Axis I, Axis II, Axis III, etc.? 
Does anyone do insurance reports?
Subject: Does anyone do insurance reports?
I called you requesting additional information in order to find out if there is any medical s/l: conjournigation OR conjure negation to work on a full-time basis.
Thanks for any help!
help new to ortho reports
Subject: help new to ortho reports
Can a person have full finger flexion at the volar wrist?
This is just a statement made in the Objective portion of the report. She is stating he has full dorsiflexion, palmar flexion and radial and ulnar deviation of the wrist. THen goes on to say "finger flexion at the volar wrist irriation with clicking"
This is not a verbatim account and she is somewhat scatterbrained sometimes so you have to fill in the blanks at times.
Tenses in reports
Do the majority of y'all change tenses when the docs dictate them incorrectly? Normally I'm inclined to, but there are times when I question it. Of course, my pet peeve is dictating a surgery that already happened, yet everything is present tense!
In this case, here's what I'm questioning:
The patient was evaluated previously, and a left inguinal hernia is reducible.
Thanks in advance!
Echocardiogram Reports
Subject: Echocardiogram Reports
I need help. I have been thrown the lions den, this man garbles his words and I am not used to typing echoes. I need to know how to is it end diastolic or in diastolic? Is only the left side measured? 
Thank you! I don't do many ortho reports.
Subject: Thank you! I don't do many ortho reports.
tx
Thanks so much! I'm new to Physical Therapy reports. nm
Subject: Thanks so much! I'm new to Physical Therapy reports. nm
x
DO NOT POST COPIES OF REPORTS. (SM)
Subject: Please kindly do not post reports (sm)
Please kindly do not post reports from your employer on this site. I have also made the Administrator aware of this.
Goldbird (Moderator)
Newbie posting reports
Subject: Newbie posting reports
Newbie, this is the stuff of which lawsuits are made. Get informed. Get some ethics. Get a clue. Good thing you do not work for my company or you would be out in a New York minute.
Can you access old reports to see if it's something used routinely? nm
Subject: Can you access old reports to see if it's something used routinely? nm
s
Can you access any of the old reports to see if he "normally" says something here? nm
Subject: Can you access any of the old reports to see if he "normally" says something here? nm
s
Thanks a bunch, now I do not have any blanks in none of my reports
Subject: Thanks a bunch, now I do not have any blanks in none of my reports
exam reports as having no problems..
Subject: exam reports as having no problems..
There are Conners reports and scales. nm
Subject: There are Conners reports and scales. nm
nm
one last try before getting these reports done.... a drug s/l clu-thy-lone.. thank you
Subject: one last try before getting these reports done.... a drug s/l clu-thy-lone.. thank you
Question to QA about spacing in reports
Subject: Question to QA about spacing in reports
Have to change from 2 spaces after a period to 1 space. If you have only one space after periods in sentences, is it okay to leave 2 spaces after colons? The reason I ask is that some of my expanders have a lot of expansions (like Neck: Supple) that have 2 spaces after the colon and need to know if I have to change them all or can I leave them be?
Any advice is much appreciated! 
thank you again, now I have no blanks in my reports. Thanks a bunch!!
Subject: thank you again, now I have no blanks in my reports. Thanks a bunch!!
Paragraphs in body of op reports.
Subject: Paragraphs in body of op reports.
When dictators dictate 'paragraph' within the body of the procedure portion of op reports, do I create separate paragraphs or ignore this request? This is not a verbatim account.
Site for sample reports. sm
Subject: Site for sample reports. sm
http://www.stedmans.com/AtWork/section.cfm/27
to be truthful, I do a lot of colonoscopy reports
Subject: to be truthful, I do a lot of colonoscopy reports
and still, no incision.
Always seen it as two words in medical reports....nm
Subject: Always seen it as two words in medical reports....nm
nm
Always seen it as two words in medical reports....nm
Subject: Always seen it as two words in medical reports....nm
nm
Stedman's Sample Reports
Subject: Stedman's Sample Reports
Link below
Question about consultation reports, Dear Dr. ttt
Subject: Question about consultation reports, Dear Dr. ttt
How do some of you do it? First line of report....
Dear Dr. ttttt,
Thank you for referring....
OR
Dear Dr. tttt, thank you for referring...
Already tried the office....no help there. (MQ-DQS)
Thanks ahead of time!
what's so difficult about producing correct reports?
Subject: what's so difficult about producing correct reports?
nm
Do not post reports for QA purposes on this board. (SM)
Subject: Do not post reports for QA purposes on this board. (SM)
Feel free to ask for "sounds like" questions on terms, words, phrases, etc. However, kindly do not post copies of your reports on this site. If you need QA, you should seek that through your employer. Goldbird (Moderator)
Zosyn and serial exams. I have had the same in reports before.
Subject: Zosyn and serial exams. I have had the same in reports before.
same reports, s/l Ti-Crope suture system
Subject: same reports, s/l Ti-Crope suture system
In radiology reports...is it ejection 'fracture'?
Subject: In radiology reports...is it ejection 'fracture'?
I have done a lot of GI reports and have always typed it as Barrett's esophagus nm
Subject: I have done a lot of GI reports and have always typed it as Barrett's esophagus nm
xxx
Can you view other reports by this doc to see what he's used before? Betadine? Dreft detergent?
Subject: Can you view other reports by this doc to see what he's used before? Betadine? Dreft detergent?
s
No other reports. Just this statement. The rest of report does not apply.
Subject: No other reports. Just this statement. The rest of report does not apply.
That confused me until I started typing Radiology reports sm
Subject: That confused me until I started typing Radiology reports sm
Normally they are plain films. However, sometimes they are actually talking about the plane or surface orientation of the exam so you have to be careful.
yes, trade you reports. Lots of noise in here too, I have a headache. TX
Subject: yes, trade you reports. Lots of noise in here too, I have a headache. TX
x
Doing hand surgery reports.... s/l "take down fusion" SM
Subject: Doing hand surgery reports.... s/l "take down fusion" SM
Patient has a dorsal dislocation and deformity of the PIP joint.
I explained to her that one of the procedures that could be done for her would be to take down fusion and relocating the joint back in place.
For future reference, have reports similar to this quite often. I do transcribe them verbatim, this
Subject: For future reference, have reports similar to this quite often. I do transcribe them verbatim, this way there is no finger pointing on what we as transcriptionists take as a "liberty" in interpretation.
If it is ever in question, they can go back to the dictators original dictation (if available) and see that is what he/she said and they are directly responsible for the content of their reports.
Hope this helps.
The patient reports her symptoms began s/l assiduously approximately two to three years ago. Is thi
Subject: The patient reports her symptoms began s/l assiduously approximately two to three years ago. Is thi
|
