verbatim, abreviations, and headings?
Posted By: c-hav on 2007-01-06
In Reply to:
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?
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
Once again, just me, but if it is not verbatim I would type out hematocrit, if verbatim "give it
Subject: Once again, just me, but if it is not verbatim I would type out hematocrit, if verbatim "give it to them".
verbatim is VERBATIM....bad advice he gave you.....
Subject: verbatim is VERBATIM....bad advice he gave you.....
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?
not an answer on headings, but
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.
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
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
Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
Subject: Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
no,not verbatim. if it were, i would type it verbatim. nm
Subject: no,not verbatim. if it were, i would type it verbatim. nm
zz
If it is verbatim, then type it verbatim.
Subject: If it is verbatim, then type it verbatim.
x
Verbatim
Subject: Verbatim
My primary acct is a verbatim but am allowed to make grammatical corrections as long as it does not change the meaning. One of my docs dictated *monna releaser*. After getting my laugh for the day, I typed *I am going to release her*....this one was not an ESL. Gotta getta good laugh once in a while to keep sanity....
No, it is not verbatim...
Subject: No, it is not verbatim...
I think I have come to that conclusion, also. There is just too much for me to try to fix it all. I'm not sure I would even know where to begin. There is just so much garbage... Thanks for verifying my thoughts, though.... :)
Verbatim - is it tib/fib or tib-fib ???
Subject: Verbatim - is it tib/fib or tib-fib ???
verbatim or not?
Subject: verbatim or not?
verbatim
Subject: verbatim
is it verbatim?
Subject: is it verbatim?
if its a verbatim acc...sm
Subject: if its a verbatim acc...sm
then you must write what you hear, if not, its up to you.
Verbatim - hep c.
Subject: Verbatim - hep c.
x
verbatim help
Subject: verbatim help
hi, i need help with a verbatim account. if they say "two PM" can i type 2 PM? or should i type 2:00 PM? and for dates, if they say "o eight," can i still type 2008?
yes, there should be, unless verbatim
Subject: yes, there should be, unless verbatim
xx
Verbatim 3/10 cc or 0.3?
Subject: Verbatim 3/10 cc or 0.3?
Would this be actual "verbatim" transcription or correct, per BOS? What would vertaim be when you have to type exactly what they say even if it is not proper? I think that is what the OP was asking. Now I am curious.
In verbatim account... HELP PLEASE
She is sating(satting) 98% on room air?
I want to change, but on verbatim, I suppose I'm not supposed to, right? I'm relatively new to this and not sure.
Verbatim account
Subject: Verbatim account
How would you type... as I have it?
ESL help..with verbatim account..
Subject: ESL help..with verbatim account..
would you type re-meet? remeet? or change to meet again... It is vebatim, but I'm not used to that yet... need seasoned advice! Thanks!
I would write it out even if it is verbatim
Subject: I would write it out even if it is verbatim
PPD is a test for tuberculosis. You aren't just writing a document to appease the doctor. You are writing a legal document that many other people may want to read, including an insurance auditor or a lawyer, neither of which may have any clue what PPD means EVEN IN THE CONTEXT OF THE SENTENCE and will have no inclination to look it up.
That's just me, someone who audits physician records and slaps them on the wrists for this like this, but you do want you want.
what is so difficult about VERBATIM....
Subject: what is so difficult about VERBATIM....
x
she said verbatim -- where's the confusion??
Subject: she said verbatim -- where's the confusion??
verbatim
adj : in precisely the same words used by a writer or speaker; "a direct quotation";
--not seeing how this leaves much room for argument.
On a verbatim account, would you
Subject: On a verbatim account, would you
actually leave this sentence as is?
She puts Neosporin on it, and she reports that in the morning it looks pussy.
TIA for any input.
verbatim acct help
Subject: verbatim acct help
General surgeon talking about frozen section pathologic exam of squamous cell carcinoma lesion. First frozen section came back with positive margins so he went back to excise a second specimen which he submitted S/L "on fos" with the new margin up. This is a verbatim account and this dictator is on 100% QA (all reports) since he is so SPECIAL. I referenced the other reports in his MD data base and found "en Fos" which would have been put there by QA before the report was signed off to the hospital. I can't find this anywhere and was wondering if anybody has a clue?
Not on verbatim--it would be PRN tylenol
Subject: Not on verbatim--it would be PRN tylenol
/
Only if the account is verbatim would I
Subject: Only if the account is verbatim would I
type 5 foot. Should be 5 feet.
mine are all verbatim *S*........nm
Subject: mine are all verbatim *S*........nm
That's unfortunately, verbatim is so unprofessional...; )
Subject: That's unfortunately, verbatim is so unprofessional...; )
x
verbatim?--gasenous?
Subject: verbatim?--gasenous?
If doc says "gasenous indigestion" and you are supposed to type verbatim, do you leave it gasenous? It's gaseous right?
Sorry, stupid question?
verbatim?--gasenous?
Subject: verbatim?--gasenous?
When typing verbatim would you commonly use a virgule like that? This verbatim thing is new to me and its got me all turned around. I cant tell if doc is saying "gasenous (meaning gaseous) indigestion" or if he is saying two symptoms the patient had, gassiness and indigestion. He says them right in a row like that.
verbatim frustration
Subject: verbatim frustration
Yes, just using Book of Style, I know the rules so that's the best I can do.
verbatim typing
Subject: verbatim typing
It would actually be "sub cu" with a space between the two, so I just learned in the last year since doing transcription for a bit over 20 years...lol..guess what it really comes down to is whatever QA thinks it should be,...but of course...she knows better than you...yeah right...NOT
It is a verbatim account so I can't add the bag ;) sm
Subject: It is a verbatim account so I can't add the bag ;) sm
He just said the patient was *ambued and could not be intibated due to facial trauma*
So, looks like this is one of those that is up in the air and probably something to talk to company QA about?
Is this a verbatim account?
Subject: Is this a verbatim account?
If not, it would make more sense like this:
It would help beneficial organisms AND commensals bacteria colonize his colon and help as a first line of protection against disease.
If not, then I would type:
It would help beneficial organisms, commensals bacteria colonozie his colon and help as a first line of protection against disease.
Since they want the beneficial bacteria and commensals bacteria to colonize his colon, there is no need for a comma before colonize.
Verbatim if that what is called for.
Subject: Verbatim if that what is called for.
If the account is verbatim, I would say OK
Subject: If the account is verbatim, I would say OK
I use it only if my account is verbatim.
Subject: I use it only if my account is verbatim.
|
