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s/l Obstutelle IV invance in plan for leg cellulitis

Posted By: Bunion on 2009-05-08
In Reply to:

Subject: s/l Obstutelle IV invance in plan for leg cellulitis

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Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?

Sorry, tried to help. Have a nice weekend.
No, not cellulitis. nm
Subject: No, not cellulitis. nm


cellulitis?
Subject: cellulitis?


maybe cellulitis
Subject: maybe cellulitis


Breast cellulitis - see msg
Subject: Breast cellulitis - see msg

garden variety gram positive bacteria and may represent methicillin resistant staph aureus that would not be sensitive to the Keflex.


Is there such a thing as garden variety?


Thanks again!!


Are you sure you are hearing cellulitis? sm
Subject: Are you sure you are hearing cellulitis? sm

Have never heard the term herald patch applied to cellulitis.
cellulitis s/l e-frez-e-a??
Subject: cellulitis s/l e-frez-e-a??


s/l *acing cellulitis*
Subject: s/l *acing cellulitis*

Regarding condition of an ulcer.


No sign of ____ cellulitis or localized infection.


Definitely not aerobic or anaerobic.


Ascending cellulitis, perhaps.
Subject: Ascending cellulitis, perhaps.

nm
you were correct...she was not saying cellulitis.....she was saying
Subject: you were correct...she was not saying cellulitis.....she was saying

Probably pityriasis rosea.  My daughter is an MT also and helped me out.


Thanks


Got it! Erysipelas cellulitis. TY! nm
Subject: Got it! Erysipelas cellulitis. TY! nm


I think he means cellulitis
Subject: I think he means cellulitis


cellulitis/ s/l ira-sip-u-lease? nm
Subject: cellulitis/ s/l ira-sip-u-lease? nm


cellulitis maybe? Usually goes along with lymphedema - nm
Subject: cellulitis maybe? Usually goes along with lymphedema - nm


I was thinking it was cellulitis, but it sounded like an M in there
Subject: I was thinking it was cellulitis, but it sounded like an M in there

x
Word help.. some type of cellulitis.
Subject: Word help.. some type of cellulitis.

It sounds like the doctor is saying "syphillis" cellulitis. It's on an elder woman's face. Any ideas?
flora digital cellulitis?
Subject: flora digital cellulitis?

The upper extremity shows flora digital cellulitis.


Anyone ever heard of flora digital cellulitis?  I cannot find it anywhere.


varicose veins? Can you hear cellulitis? nm
Subject: varicose veins? Can you hear cellulitis? nm


s/l Ligacin 600 mg IM - pt. has spider bite with cellulitis.
Subject: s/l Ligacin 600 mg IM - pt. has spider bite with cellulitis.

 


Cellulitis treated with vancomycin and s/l zosyn? nm TIA
Subject: Cellulitis treated with vancomycin and s/l zosyn? nm TIA

x


Pt with venous stasis, cellulitis, Chron's sm
Subject: Pt with venous stasis, cellulitis, Chron's sm

Currently on s/l sinzia treatment.
fissuring between toes with cellulitis & erythema: ASSM: s/l ara-cip-o-lus. nm
Subject: fissuring between toes with cellulitis & erythema: ASSM: s/l ara-cip-o-lus. nm

thanks.
Child with ear cellulitis. Prescribed s/l Ceftin ear 300-mg capsules
Subject: Child with ear cellulitis. Prescribed s/l Ceftin ear 300-mg capsules


cellulitis: skin irritated but not warm. Might be s/l 'broney' changes. Not hearing bony. nm
Subject: cellulitis: skin irritated but not warm. Might be s/l 'broney' changes. Not hearing bony. nm

,,
Plan
Subject: Plan

CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.


I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.


Plan help please!
Subject: Plan help please!

  I am a new, and need some help.  after the doctor says plan he lists the medications he has prescribed.  He does not number them and I am used to them saying medications and then listing (1, 2, 3)   Do they usual do that?  Should I leave it like he says it?  Example: 


PLAN:


Ecotrin 1 p.o. b.i.d. with meals.  Keflex 500 mg p.o. q.i.d. for 4 days..  Follow-upl with me within the next 10 days.


 


thanks!


Plan help please!
Subject: Plan help please!

That all depends on the QA person reviewing the report.

I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).

I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.


Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you


Do you have to have a plan?
Subject: Do you have to have a plan?

Where I work, if they don't say "plan", they don't get a "plan".


That's what I plan to do.
Subject: That's what I plan to do.

I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan

1.      Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago.  I asked him to repeat it, but he forgot.  We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly.  He is not symptomatic.


 


I keep listening over and over to this, and this is all I can make out.  Any clue what he might be referring to??? TIA


assessment&plan help!
Subject: assessment&plan help!

If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?


 


ASSESSMENT:



  1. Bilaterally arm numbness.
  2. Nausea.
  3. Health maintenance recommendations.

 


PLAN:



  1. Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion.  She will be referred for MRI with cervical spine.  Patient may need EMG to further access her numbness.
  2. Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn.  She does have chronic nausea and this may be a sign of stomach reflux.  She will be tried on Nexium 40 mg one q.d.  Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night.  We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism.  ___ problem health maintenance and in regards to increase her exercise and changing her diet.  Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram.  When she follows up to see me we will discuss potential options for colon screening.  Patient is to follow-up with me in approximately 1 month time. 

assessment and plan
Subject: assessment and plan

I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
starts plan
Subject: starts plan

it starts the plan then says ??? flonase 2 sprays each nostril
Sounds like a plan to me!!
Subject: Sounds like a plan to me!!

Thanks!!
s/l her-plan-jet-ick lesions
Subject: s/l her-plan-jet-ick lesions

s/l her-plan-jet-ick lesions in the mouth and throat


this is a 17 month old with excessive drooling and fever.


that sounds like a plan
Subject: that sounds like a plan

nm
Is this directions for something or what? A plan at the end of a scan? nm
Subject: Is this directions for something or what? A plan at the end of a scan? nm

s
In plan he very plainly says says need to rule out
Subject: In plan he very plainly says says need to rule out

Patient fell and injured right ankle. Sentence in question: She is significantly tender in the s/l coronal ligament s/l and the (or in the) right ankle.

Plan: MRI to rule out coronal ligament tear.

This is very clear - just cannot document it anywhere and don't want to flag it as it's very clear - just unsure and hoping for documentation or someone that has heard it.
Where would you begin the PLAN if the dictator does not say so?
Subject: Where would you begin the PLAN if the dictator does not say so?


ASSESSMENT: We discussed options for Jeff. At this point, a month after the injury, an MRI, potential surgical interventions, etc., ultimately doing as well as he is, he is just going to keep it in mind and be careful with his lifting. He drives a forklift, apparently on a regular basis, but we are going to forego further work up at this point. We also got int a discussion of routine health care maintenance. He will plan on complete physical in October, starting this year. I will put a standing order at lab at this point for him, for a UA basic metabolic fasting lipid panel and PSA. We will go from there.

Help with sentence. This is doc's treatment/plan: sm
Subject: Help with sentence. This is doc's treatment/plan: sm

The sentence just doesn't seem right to me. Any input appreciated!


" Examination, evaluation, simple avulsion nail plate, 3rd left lateral aspect nail plate avulsed paronychium performed under anesthesia."


Plan: Check CMP and s/l iris ads
Subject: Plan: Check CMP and s/l iris ads


In plan, doc says check s/l FH LSH. How would this be typed --
Subject: In plan, doc says check s/l FH LSH. How would this be typed --


plan of coagulation? planned? WAG
Subject: plan of coagulation? planned? WAG


ASSESMENT/PLAN COMBINED?
Subject: ASSESMENT/PLAN COMBINED?

WHen doing a SOAP NOTE


Can you Combine Assessment/Plan or are you supposed to seperate?



Even if doctor doesn't dictate a new paragraph? Thanks!


Thanks!!! no he says pila plan but cant find that--see more
Subject: Thanks!!! no he says pila plan but cant find that--see more

he diagnosed condition as blepheritis so that will work.  thank you!!!!!


Patient with pneumonia - plan for... s/l R-cat consult??
Subject: Patient with pneumonia - plan for... s/l R-cat consult??


is this under procedures? plan? could you give the whole sentence?
Subject: is this under procedures? plan? could you give the whole sentence?


s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan


jeez never mind... it's "clear plan" =)) NM
Subject: jeez never mind... it's "clear plan" =)) NM

x
Plan: s/l munster removable splint.
Subject: Plan: s/l munster removable splint.

Patient is status post left distal ulna stabilization.