Expanding in impression/assessment

Negative for pulmonary embolism or dissection. Moderate coarse infiltrate left lower lobe. Scattered area of ground glass infiltrates and s/l normal focus of parasegments on the right. Abnormal hilar lymph node s/l pipathy with asymmetric enlargement nodes s/l axial lateral left greater than right. ...

I've been an MT for over 10 years and have always just typed IMPRESSION, even when there are multiples, but I'm seeing other MT's type "IMPRESSIONS" and also "PLANS" when there are more than one, even when the doctor is only dictating IMPRESSION (though we would change DIAGNOSIS to SES if more than one but not dictated). I searched the archives and found one mention of this before, but there wasn't much conclusion on the matter. So what say ye? ...

I know that according to AAMT we are not supposed to put abbreviations in the Impression/Diagnoses sections, but does that include ALL abbreviations? Or just ones pertaining to diseases? For instance, are we supposed to spell out MRI in the impression? Or just diseases, like PUD or COPD? I'm a bit confused because I put "MRI" in the impression and QA left that as is, but I also put "PT" and they expanded it out to "physical therapy." Does anyone know? Thanks in a ...

When you are supposed to expand out DC I've always thought it as discontinue (as in meds). In this case someone is having stitches removed and the doc says DC of stitches. Would I be correct to transcribe discontinuation of sutures? I can understand it, but it just looks odd to me. Thanks ...

Good morning everyone. I'm a bit confused about headings: If "GYN" is dictated in a heading, do you expand it to "GYNECOLOGIC"? I remember from my training that you do; however, I've seen reports that show it as not expanded. D ...

I started using AutoCorrect for my expanders. The problem is when I use them followed by a period they won't work. So "t" doesn't turn into "the" just "t." They work after any other punctuation or a space. I've scoured the internet and Microsoft forums and I can't find a thing. I've tried turning off the auto-caps and that doesn't work. Help? ...

I got a style error minor deduction for this, because it could also refer to "benign prostatic hyperplasia." I was actually aware of this terminology controversy in the medical community in terms of what the actual meaning is, but I've never once had "benign prostatic hyperplasia" dictated in over 18 years of MT, regardless (has anyone else?). However, I should somehow intuit that Nuance wants it done this way (though I've been expanding it for over 2 years now with never a corre ...

With instatex, there are phrase entries on the left and word entries which show up on the right side. To expand the phrase entries you just hit the space bar after the short entry, but how do you make the word entries expand? And how do you choose the second on the list, or the third, ect. I cannot figure this stupid thing out, even after going through the help menu. Thank you to anyone that can explain this!! ...

Gallbladder was removed, and the impression was "questionable evolving *PYRANASE* versus phelbitis"...anyone know? I have no clue! :( ...

My question is if you can take the test in stages or if you have to sign in and take the complete test all at once. The website doesn't say and yes, I have e-mailed them to ask, but in the meantime, I am curious if anyone knows. I am just worried about being interrupted and having to walk away and losing time or if I can just sign out and come back in to "hold" my time. They give you 3.5 hours to complete it. ...

I have a dictator will dictate the Assessment/Plan with a number for the problem and a letter for the plan (1. Gout. A. Labs in the morning. B. Medication, 2. Etc. A. B., 3. A.) I have always just ignored the letters she gives me and not put them, but I was wondering today if I am suppose to. It is not a verbatim account and I never got in trouble for not putting them. I tried looking this up in AAMT BOS but maybe I am not looking right ...

anyone hear of "SMACK" on the assessment and plan of a PE? ...

EMS responding to a patient who just had ablation for SVT last week and is complaining of weakness and dizziness. Cannot find with much searching. Thanks for your help! ...

I am beyond frustrated. Is there anyone out there that has taken the assessment testing that is supposed to be completed by 02/14? There is 1 test that I have taken at least 50 times and cannot pass it. It's the one with the Asian woman who has shoulder pain. I have put in every combination there is, and it still says "incorrect." My HDSM says I have to pass it for the testing to be considered "complete." Apparently there is ...

Dementia supervision risk assessment, and it sounds like he is saying Lobman or Logman for one-on-one supervision. Thanks for any help! ...

Mental Status: s/l CHEM or KIM bedside assessment was positive for ongoing delirium. Thank you!!! ...

Hello, Smart People- Has anyone ever been asked to take a personality assessment when you're in the running for a job position? I applied for a patient sitter position at a local hospital and they said I was in the running and would I please take an assessment. It was a personality assessment (I could just tell), but I don't think it was the MMPI--the Minnesota Multiphasic Personality Index. There weren't enough questions for that one. FYI: The job description for which I'm ...

Just wondering has anyone been let go from Nuance for not making their 99.5% quality assessment? I can't seem to hit the 99.5% but I am always being asked to work extra, so I don't know how serious not hitting the 99.5% is? Anyone have anything to share on this subject? ...

Is this supposed to be left as MRSA in the assessment?? The client profile says nothing about it? I thought we had no abbeviations in the assessment unless the client profile stated that. ?? ...

I'm looking for what s/l "begalrithm" Risk Assessment for breast cancer. Thanks for any help! ...

What ever happened to our weekly assessment/review of our ASR production? I received 1 evaluation back in November around Thanksgiving and have not received another one. Am I wrong in thinking we were supposed to get one weekly. Has anyone gotten any more than their original one? Maybe I was so good, they just said, she doesnt need it, LOL My guess, they realized how much it was going to cost them to pay someone to do this and nixed it already. ...

The patient is planned for surgery. The physician will come and "preop" him the day prior to surgery. How would you expand that? Thanks for any suggestions. ...

Sounds like sym-et-ri-can or si-vit-ri-can 50 mg ...

At my company there are a few exceptions to expanding the diagnosis section (MRI, CT), but my question is when the dictator says "C2 lesion" in the diagnosis should I expand that to cervical vertebra 2 or leave as C2? Any help would be greatly appreciated. Thanks. ...

Has the rules changed? I always expand disease abbreviations under the diagnoses heading? ...

ASSESSMENT AND PLAN: Pulmonary toileting. The patient will use a s/l "cuck-ugh-la" 8 to 10 times a day. ...

the patient to be more ticklish than pain. Dictator has a very strong accent, but it sounds like luncal. Thought pehaps it might be truncal, but I hear the L vey clearly. Any help would be greatly appreciated. Thanks. ...

Expanding in impression/assessment - JustDoingMyThing

Normally, you would not expand lab values in an - impression.diagnosis, assessment, etc.

I should have said lab "names," not values. - NM

PSA should be an acceptable abbreviation - in diagnosis

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