not an answer on headings, but
Posted By: grace on 2009-05-28
In Reply to: Headings - Cora
Subject: not an answer on headings, but
Sorry, I don't have a quick answer about your headings, but I wanted to let you know that your first sentence should be 2 sentences: Orientation and language are normal. Fundi with sharp disks bilaterally. (Fundi and disks/discs refer to the eyes, nothing to do with orientation or language.) Good luck with the headings - I still get confused sometimes on them too if I don't have a specific format to follow.
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Headings
Newbie here. If a doc dictates a laboratory data and lists lab values, then talks about x-rays and ekgs, do you include that in the lab section or make a separate heading for x-rays and ekgs (what would you title that section?). Thanks for any info.
Headings
Subject: Headings
I am transcribing a History & Physical Examination Report (Neurology)
The headings confuse me terribly. What would the heading be for the following:
Orientation and language are normal fundi with sharp disks bilaterally.
I have the following:
NEUROLOGIC: Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on tandem walk she really has difficulty with that. She does not line up her toes easily and loses her balance very easily with that. (Is that the correct heading?)
Also, does anyone have a good website for determining headings?
headings
Subject: headings
Thanks so much. Does it get better?
Headings
Subject: Headings
If in a report , broke into 2 sections.. MRI of the Right leg then left..
and said
History
Technique
then
Technique
History
would it be a good idea to switch order for consistancy?
If QA has no recommendations, you don't have to have headings in there at all. Just do the report
Subject: If QA has no recommendations, you don't have to have headings in there at all. Just do the report
s
verbatim, abreviations, and headings?
Subject: verbatim, abreviations, and headings?
typing verbatim. In headings PREOPERATIVE DIAGNOSIS and POSTOPERATIVE DIAGNOSIS, when doc says same for POSTOP. Do you type same when typing verbatim?
Progress Note headings?
Subject: Progress Note headings?
I really want to hear Chief Complaint, but I’m sure he starts with Cardio. Thanks anyway.
Progress Note headings?
Subject: Progress Note headings?
I can’t hear the “tat” part, but that sure makes sense. I like the cardiovascular, too, except this is talking about GERD - could that be connected to Cardiovascular system?
Headings are allowed to be added.
Subject: Headings are allowed to be added.
It would look weird without a heading. Thanks.
History & Physical Headings
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
History & Physical Headings+1>?
Subject: History & Physical Headings+1>?
Thanks. One more question. What headings do you add if not transcribed to the H & P?
Depends on what your QA says, but I separate out the entities and only use headings if
Subject: Depends on what your QA says, but I separate out the entities and only use headings if
s
Would depend on your account and whether they allow headings where necessary or not. If heading is w
Subject: Would depend on your account and whether they allow headings where necessary or not. If heading is warranted, I would use CLOSURE.
Interstital tissue and pelves need headings?
Subject: Interstital tissue and pelves need headings?
Spleen: The spleen has a thin fibrous capsule. Malpighian bodies are indistinct the sinusoids are moderately widened.
Liver: Sections of the liver show a thin fibrous capsule. Multiple small fatty vacuoles are noted in the cytoplasm. Portal spaces are fairly small in size. There is mild widening of the sinusoids in the central zones.
Kidneys: The kidneys have a thin capsule. The cortices that show glomeruli of normal appearance. The tubules are not remarkable.
Interstitial tissue showed no note worthy change. The pelves are not remarkable.
In this instance.. does the interstitial tissue and pelves need their own headings.. or is this correct?? Thanks
Mo, I just sent an e-mail to the doc to get answer. Thx for help. Will post answer. THX
Subject: Mo, I just sent an e-mail to the doc to get answer. Thx for help. Will post answer. THX
ENT answer
Dorland refers to "great" auricular nerve when defining nervus auricularis magnus
answer
Subject: answer
He is on several meds, and 105/70 is As Low as it needs TO be. DOC doesn't want it to go any lower, so He is going to reduce one of the meds (Norvasc) some. They talk so fast that it's hard to tell if they're saying hyper or hypo.
Right Answer!!
Subject: Right Answer!!
Sted's Ortho has this:
Electro-Acuscope
Electro-Acuscope electroacupuncture
Electro-Acuscope 85 stimulator
answer
Subject: answer
addisonian syndrome
the answer?????? ..................NM
Subject: the answer?????? ..................NM
/
the answer was already given.....NM
Subject: the answer was already given.....NM
answer
Subject: answer
There is a rally, and also there is a balloon. But rally and balloon as one word... I don't know.
and the answer was
Subject: and the answer was
folliculitis.
thank you both so much for the answer
Subject: thank you both so much for the answer
See answer.
Subject: See answer.
Spontaneous intracranial hypotension.
I second that answer.
Subject: I second that answer.
xx
Answer Med
Subject: Answer Med
Could you be hearing Metoclopramide (generic of Reglan)?
thanks for the help sm for answer
Subject: thanks for the help sm for answer
"dorsolateral slit, prepuce" is what it ended up being. Thank you for the help.
I like your answer!
Subject: I like your answer!
The answer is NO.
Subject: The answer is NO.
(Just kidding - I'm punchy after seeing all these incomplete questions and now answer posts that aren't assigned to a question!)
Answer!
Subject: Answer!
Don't know about BOS, but leukocyte esterase is just a test for an enzyme that might indicate a uti...so in my experience, it's either a positive or negative result. If he gives you actual numbers or ranges (10-20), then he's talking about actual white blood cells (leukocytes).
At least that's my understanding.
Hope that helps!
QA answer
Subject: QA answer
If you cannot find it in the BOS, then chances are it does not matter.....unless the client profile specifically says not to abbreviate it should be OK.......
Answer
Subject: Answer
There is NO hyphen in followup. It is either one word or two words.
Verb is follow up. (The patient will follow up with me).
Noun is followup. (The patient will be seen in followup in 1 week).
Hope that helps! Never use a hyphen with followup.
your answer
Subject: your answer
When doc dictates those just type it like you have it with the abbreviation first and then parentheses around the rest.
Thanks for your help. Just not sure, but I will let you know when and if I get an answer. NM
Subject: Thanks for your help. Just not sure, but I will let you know when and if I get an answer. NM
ss
Your answer is better !! nm
Subject: Your answer is better !! nm
See below, same answer.
Subject: See below, same answer.
don't have another answer, but
Subject: don't have another answer, but
great website I use is http://health.ucsd.edu/labref/Labref.html
Can you not answer?
Subject: Can you not answer?
I appreciate your answer.
Subject: I appreciate your answer.
nm
Answer
Subject: Answer
Apposition is when something is positioned side by side or fitted together like closing the skin for an incsion....the two sides are in apposition. Opposition is when things are opposite of each other, like the ability to move your thumb in contact with your fingers.
Oh well, my answer was Tc-99m
Subject: Oh well, my answer was Tc-99m
xx
Possible answer for DR
Subject: Possible answer for DR
DR: Degeneration reaction or reaction of degeneration [muscle fibers] according to my copy of Stedman's Medical abbreviations, acronyms, and symbols.
ref for you for my answer. sm
Subject: ref for you for my answer. sm
Traube semilunar space
a crescentic space about 12 cm wide, bounded medially by the left border of the sternum, above by an oblique line from the sixth costal cartilage to the lower border of the eighth or ninth rib in the midaxillary line and below by the costal margin; the percussion tone here is normally tympanitic, because of the underlying stomach, but is modified by pulmonary emphysema, a pleural effusion, or an enlarged spleen.
Answer
Subject: Answer
It is Klebsiella (bacteria)
answer
Subject: answer
Could it be hematopoietic ?
here's your answer
Subject: here's your answer
cotyledons
answer
Subject: answer
it's high sensitivity CRP (C-Reactive Protein)
answer
Subject: answer
bilirubin or urobilinogen?
both words are in a UA
answer
Subject: answer
Narcan? It's what they give for an overdose.
Answer
Subject: Answer
PE protocol
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