pt. came in with appendicitis, but in postop notes, dictator keeps saying left epi/appe?
Posted By: mm on 2007-11-27
In Reply to:
Subject: pt. came in with appendicitis, but in postop notes, dictator keeps saying left epi/appe?
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
Nurses' notes or nurse's notes or nurses notes?
Subject: Nurses' notes or nurse's notes or nurses notes?
I am so confused on this one. I have typed it several different ways over the years. Do I really need to put any apostrophe in there at all? Thanks!
Nurse's notes reviewed or nurses notes reviewed? nm
Subject: Nurse's notes reviewed or nurses notes reviewed? nm
x
appendicitis
Subject: appendicitis
purulent maybe
Appendicitis.
Subject: Appendicitis.
The mesoappendix was then elevated and divided with the endoscopic stapler. Hemostasis was good and the appendix was placed in a ??_________ and extracted through the left lower quadrant port site.
It sounds like pletement fack or something silly like that.
Thanks!
Appendicitis sign
Subject: Appendicitis sign
Okay, I know I know this but I'm drawing a complete blank. The patient has a positive obturator sign and a positive ?Rostitch? sign. Help!
Appendicitis sign
Subject: Appendicitis sign
I believe you are looking for Rovsing's sign.
Appendicitis with pearly rupture?
Subject: Appendicitis with pearly rupture?
Acute appendicitis with __________rupture.
s/l pearly
appy; slang for appendicitis
Subject: appy; slang for appendicitis
nm
It's heel tap, most likely. Done to check for appendicitis, I believe. (sm)
Subject: It's heel tap, most likely. Done to check for appendicitis, I believe. (sm)
They tap the bottom of the heel, and if it causes pain in the abdomen, then the patient most likely has appendicitis. Don't know why....
google heel strike and appendicitis
Subject: google heel strike and appendicitis
nm
Acute appendicitis, possible s/l Les Bence with cecal transposition.
Subject: Acute appendicitis, possible s/l Les Bence with cecal transposition.
holiday...is the dictator an Arab dictator? nm
Subject: holiday...is the dictator an Arab dictator? nm
x
type what dictator said, dictator is not incorrect.....
Subject: type what dictator said, dictator is not incorrect.....
.
Rovsing sign, pain over McBurney's point when looking for appendicitis. nm
Subject: Rovsing sign, pain over McBurney's point when looking for appendicitis. nm
s
s/l Repleva 21/7 for postop c-sec?
Subject: s/l Repleva 21/7 for postop c-sec?
Pre and Postop diagnosis is
Subject: Pre and Postop diagnosis is
cholecystitis but he says the procedure is an appendectomy?? That cannot be right or am I crazy?? It is clear as could be.
postop surgery for what?
Subject: postop surgery for what?
what surgery?
postop exercise sm
Subject: postop exercise sm
Surgery was a total abdominohysterectomy and bilateral salpingo-oophorectomy was done with morcellation technique, significant enterolysis and uterosacral plication for vaginal suspension. Postoperatively doc says she was doing her s/l base-ense-exercises and ambulating........
s/l darka postop shoe? SM
Subject: s/l darka postop shoe? SM
Patient with diabetes who has an ulceration on her foot - dictator says patient will use Panafil and Fibracol, and "she will continue to wear the darka postop shoe with a forefoot wedge."
dr is describing postop incisions- sm
Subject: dr is describing postop incisions- sm
She does have some erythema in her perineum and her buttocks. She is not tender in this area, and there is no s/l screpadence or sucrepadence or induration noted.
Anyone doing MT should know if a period is required after postop.
Subject: Anyone doing MT should know if a period is required after postop.
Where did you get your education? If you don't know that much, you should not be in this field as you are a disgrace to the MT field.
Would think "split" sutures, unless this is postop a few days &
Subject: Would think "split" sutures, unless this is postop a few days &
s
as postop diagnosis says severe central
Subject: as postop diagnosis says severe central
stenosis at L3-4 and 4-5 and s/l fraying/framing?? stenosis at 3-4, 4-5, and 5-1
Pt with postop bleeding txd with s/l QL and polystyrene mixture. (nm)
Subject: Pt with postop bleeding txd with s/l QL and polystyrene mixture. (nm)
Funny thing, I had this yesterday and left 3 blanks that QA also left blank.
Subject: Funny thing, I had this yesterday and left 3 blanks that QA also left blank.
x
pain over the left hip and a biopsy of the left s/l SA pablum showed adenocarcinom
Subject: pain over the left hip and a biopsy of the left s/l SA pablum showed adenocarcinom
n
Could be right; they often use an agent to deaden nerves for postop pain. NM
Subject: Could be right; they often use an agent to deaden nerves for postop pain. NM
..one day postop removal of a glomus tumor. We also had to do an eardrum repair. nm
Subject: ..one day postop removal of a glomus tumor. We also had to do an eardrum repair. nm
probably means left anterior descending. Instead of saying LAD, just saying left AD.
Subject: probably means left anterior descending. Instead of saying LAD, just saying left AD.
x
Drain was removed at this first postop visit- discontinued makes the most sense. Thanks!
Subject: Drain was removed at this first postop visit- discontinued makes the most sense. Thanks!
CXR: Ill defined density seen in the right s/l PROVERBUN apex, which may represent postop change. NM
Subject: CXR: Ill defined density seen in the right s/l PROVERBUN apex, which may represent postop change. NM
type of shoe wear for postop cuneiform fracture? s/l cunua nm
Subject: type of shoe wear for postop cuneiform fracture? s/l cunua nm
is this dictator ESL (foreign dictator)?....
Subject: is this dictator ESL (foreign dictator)?....
if ESL, I would either blank him or give him that Avodart but the other one I haven't a clue and would have to blank there too. Sorry :(
S/P left total knee reconstruction. On exam, has a palpable s/l clod defect on the left knee.
Subject: S/P left total knee reconstruction. On exam, has a palpable s/l clod defect on the left knee.
:-)
op notes
Here is a list from my favorites. Hope they are a little bit helpful. I think they are all still good sites.
Op note sites:
http://www.mt-stuff.com/ent.html
http://mtdesk.com/gen.shtml
http://www.medical-library.org/journals2a/tubal_ligation.htm
http://www.mtdaily.com/samples.html
http://www.nezhat.com/oplap_abst.htm
http://www-personal.umich.edu/~aalin/vitalsigns/contentappendix/cntappsamplenotes.html
op notes
Subject: op notes
I have never encountered such a rule. I don't generally listen to where the dictators want their paragraphs, though. They usually put in way too many. I start a new paragraph after the prep and drape description and a I start a new paragraph for the closing of the wounds. I add new paragraphs when the surgeon is addressing a new area. That's just my style of transcribing. I'm not saying it's the right way to do it. It just makes sense to me and I would think it is easier to read and comprehend that way.
take notes!
Subject: take notes!
Whenever I have to spend a lot of time looking something up, I make sure to write it down. It's worth it.
I don't do op notes! LOL
Subject: I don't do op notes! LOL
thanks - i usually do ER notes so not familiar with that!
Subject: thanks - i usually do ER notes so not familiar with that!
Resources for OP notes?
Subject: Resources for OP notes?
Is there anyone here who does operative notes and gynecology notes who could give me some websites to use for resources? I am on an OB/GYN account and have operative notes. I have trouble sometimes with the specific surgical instrument names and would greatly appreciate any help. Thanks in advance.
Resources for OP notes?
Subject: Resources for OP notes?
My suggestion would be to purchase (if you do not already have)OB/GYN, equipment and surgical word books (Steadman's) my choice and you would be equipped to better perform your job.
OP notes resources
Subject: OP notes resources
I would do that but we are on a tight budget as we just bought a house and are getting in married in september.
Paragraphs in Op notes
Subject: Paragraphs in Op notes
I have noticed that when I transcribe an Op note as the dictator dictates it, starting a new paragraph as dictated...that QA always removes the spacing between the paragraphs.
Is there some rule in transcription that you don't break an op note into paragraphs? The client profile does not say anything about this.
SOAP notes
Subject: SOAP notes
Was wondering if there are any websites out there that gives sample reports for SOAP notes. Just trying to figure out which is the best way to do it with paragraphs between each heading or all scrunched together. Just want to see what is done more of. I realize it might depend on the clinic, dr, hospital, etc, but just want to get an idea.
Thanks Carla
Thanks so much! I'm taking notes!
Subject: Thanks so much! I'm taking notes!
SOAP notes
Subject: SOAP notes
transcribing for 7 1/2 week old child. Dictator states fontanels are flat, sound like "contrapendalence" are normal.
I have parascapular in my notes.
Subject: I have parascapular in my notes.
Think just nurses notes. IMO. nm
Subject: Think just nurses notes. IMO. nm
Nurse's notes..
Subject: Nurse's notes..
An apostrophe shows ownership. :-)
Does anyone know a good website for op-notes...
Hi, does anyone have any websites that are good for surgical words? I have limited books, try to use Int. for most everything. I use surg. instrument sites to look up tools, but not always successful or spend too much time looking through their quite extensive catalog. Thanks for your help...Suzy
Does anyone know a good website for op-notes...
Does anyone now a good website or two for surgical notes? I at times use a surgical instrument site but if I don't know how to spell something, I have to look through extensive catalog listings...or if I get a foreign accent and can't make out what he is saying, then I have big problems, so a site that has sample notes would be a big help too. Thanks for your help. Suzyq
|
