office note help
Posted By: ubby_g on 2009-04-27
In Reply to:
Subject: office note help
I am doing a otology office note and the doctor dictates "during his ___ (s/l relic or realick) surgery, there was recurrent cholesteatoma and during dissection, the _____ (s/l flick-plate)became free
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office???
Subject: office???
Could be..
You don't know my office...
Subject: You don't know my office...
It would appear that not only do they not go by AAMT, but they make it up as they go along. And if there are two rules contradicting each other, better pray the document is not the one they pick for QA.
If you are saying like dr smith's office
Subject: If you are saying like dr smith's office
would it be John Smith's,MD or would it be John Smith, MD's office? Where would the appostrophe go?
This was an office visit. Thanks
Subject: This was an office visit. Thanks
Could it be office appointment?
Subject: Could it be office appointment?
Office visit H&P- Thanks! nm
Subject: Office visit H&P- Thanks! nm
That's it!! Just confirmed via office, too. Thank you!! (nm)
Subject: That's it!! Just confirmed via office, too. Thank you!! (nm)
xx
EKGs in my office?
Subject: EKGs in my office?
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
Thanks for the help, Im going to flag it for the office to relisten. nm
Subject: Thanks for the help, Im going to flag it for the office to relisten. nm
He says "I did a bi ox today in the office and was 99-100% on room air.
Subject: He says "I did a bi ox today in the office and was 99-100% on room air.
Might just be the History and Physical that's back at the office, or the H&P. nm
Subject: Might just be the History and Physical that's back at the office, or the H&P. nm
s
Would depend on the context. In the office setting, it could be. I don't
Subject: Would depend on the context. In the office setting, it could be. I don't
s
Context, please! What are you doing - xray, scan, office visit, etc.?
/
Check my spelling--I'm nowhere near my office. Calibri forceps. nm
Subject: Check my spelling--I'm nowhere near my office. Calibri forceps. nm
x
yes it is capitalized; referring to Dr. Smith's specifric office
Subject: yes it is capitalized; referring to Dr. Smith's specifric office
nm
Gals in my office are taking a vote, we are arguing about 7-French SM
Is it 7-French diagnostic sheath. Hypen or no? Driving me bonks, someone clear this up? Many references state different things.
A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for sm
Subject: A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for sm
A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for an R&M C&S which returned unremarkable.
I know what C&S is. What is the R&M????? help please Donna
Maybe 'hold, on call' to hold the patient in the office for the on call xray? nm
Subject: Maybe 'hold, on call' to hold the patient in the office for the on call xray? nm
s
noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy
Just wondering if there is any general rule about transcribing noteworthy.
Also, status post; status-post.
Thank you.
Op note ref. SM
Subject: Op note ref. SM
http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note
? pulse ox 99% on room air which is normal per ______ interpretation.
ER note thanks
Subject: ER note thanks
Thanks, practically sure it was per the ER physician reading. So, will be ready for next time!
At the end of OP note, he says
Subject: At the end of OP note, he says
what sounds like "mick" instrument and needle count.
On another, says "sponge, _____and instrument" and that sounds like "lab". Any clues are appreciated. Thank you!
OP note help please sm...
Subject: OP note help please sm...
mild (s/l-fibulations-) with changes on the surface of the condyle
Of note..... I want
Subject: Of note..... I want
to thank everyone so much for all the help I have received on this website since I have become an MT. Bless everyone of you. I hope one day to help those also asking questions as you all have me.
Op note
Subject: Op note
Dictator says: Local Xylocaine 1% anesthesia 'arfate' cannulated.
What is the 'a' word?
me again - same op note :(
Subject: me again - same op note :(
The wound was irrigated and rough edges were S/L RASSED. 
op note help
Subject: op note help
Using an up-biting basket and a S/L 405 shaver a medial meniscectomy was performed.
TIA!
OP NOTE HELP
Subject: OP NOTE HELP
The iliotibial band was then split inline with the incision and retracted anteriorly and posteriorly with a _____ bow. s/l charming.....
The procedure is a cemented bipolar hemiarthroplasty left hip.
OP NOTE STILL
Subject: OP NOTE STILL
Should have went further in the note...sorry...another blank is
Attention was directed to the proximal femur, which was prepared with a box-cutting chisel, _____ canal finder and a trochanteric router this sounds like "chauney"
ESL help with op note
Subject: ESL help with op note
She says: With forceps and a S/L barpotta knife the lesion was excised. (This is excision of a lid nodule). 
have another on this same note - sm
Subject: have another on this same note - sm
Bilateral elbow rheumatoid arthritis. The left side is more advanced with (s/l)'spectus articulusdamage than appears on the right side
op note help
Subject: op note help
This is an excision of a breast nodule. Two questions:
1. The area was prepped with s/l Cloraprep
2. The needle was grasped with an S/L Alice clamp
See note below
Subject: See note below
This is the context of the report. It sounds just like Waddellian. He says this quite a bit and it stumps me every time....
PSYCHIATRIC: The patient was alert and oriented x3 with a somewhat depressed and scattered mood, being very jumpy and quickly agitated by minimal movements or pressures in various areas such as supporting the leg while doing musculoskeletal motor examination for neurologic examination. The patient definitely showed some ____________________ symptoms through our examination. When the idea of psychiatric help in this manner was brought up in this case, the patient seemed almost excited to know this was a coming event.
op note help
Subject: op note help
This is a partial medial meniscectomy and synovectomy.
large s/l type 1 plica present - is type 1 correct?
This was resected back to a stable configuration using an s/l oslite shaver or 8 inch shaver (he mumbles) ???
op note help
Subject: op note help
This is for an amputation of the left hallux.
Upon induction of IV sedtion a total of 10 ml of 0.5% Marcaine plain was infiltrated in a S/L Mayo block type fashion.
Mayo block???
note, no h on the end.
Subject: note, no h on the end.
x
Op note help
Subject: Op note help
ORIF surgery: Intraoperative s/l FLORA showed excellent alignment of the implants.
Note put above
Subject: Note put above
what does it mean when she dictates "note, put above..." before a sentence? i'm confused.
not 100% sure, but I don't think so--also, another note
Subject: not 100% sure, but I don't think so--also, another note
should your first part of your message say "afferent pupillary defect" ?? instead of papillary
See note
Subject: See note
This is what you are looking for.
http://www.fda.gov/cdrh/pdf/p000040.html
Lilly
Thanks for everyone's help. I sent it in with a note for them to let me know. sm
Subject: Thanks for everyone's help. I sent it in with a note for them to let me know. sm
Hopefully, by boss will get back to me, and I will let you all know. Thanks again!
op note
Subject: op note
s/l groshime single lumen catheter
see note
Subject: see note
first word may be lucencies second word might be bezoar
Thank you! Will make a note of it. nm
Subject: Thank you! Will make a note of it. nm
x
Surgical note. sm
Subject: Surgical note. sm
A tornikot was used for hemostasis. He actually spelled it with a "c" rather than "k", but I can find neither.
He said, "not tourniquet, but tornicot".
clinic note help
Subject: clinic note help
Patient is accompanied by her husband today who is very concerned regarding recent symptoms of numbness and tingling in the lateral aspect of the left and right arm. ***This is been ongoing x 2 to 4 weeks.**** . is this the correct way to transcribe this? The last sentence is the questionable.... thanks for all your help!!
clinic note
Subject: clinic note
thanks for your help, I am a new MT and I am a little confused with some things. thanks again!!!
clinic note
Subject: clinic note
the doctor says "this has been ongoing times 2 to 4 weeks" i was not sure how to transcribe that.
clinic note
Subject: clinic note
Your a wonderful help!!!!
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