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function scale - tb

Posted: Jan 31, 2013

For *pain* scale (1-10), i was taught to add the range if not dictated.

Example:

D: Pain was a 5.

T: Pain was a 5/10.

I'm not familiar with *function* scale. This is a spine surgeon. This particular patient is having neck and shoulder issues (if that matters). Is there a specific *function* scale? If so, what is the range and do you add it like the pain scale, or do you guys just type as dictated without adding the range?

I never add anything not dictated - sm

[ In Reply To ..]
If they dictate pain was a 5, that's what they get, in either case - pain or "function" scale.

thanks - tb

[ In Reply To ..]
I went through the HPI SUM program, and it seems to me they promote what I call "aggressive" editing compared to what I've experienced on the job. For example, the program recommends to never use acronyms in assessments/diagnoses (expand if dictated), which I don't. There are many things I learned right away to NOT do even though I was taught otherwise.

I appreciate your reply to my question.

how would you expand MS? - curious

[ In Reply To ..]

Function scale - anon

[ In Reply To ..]
What did the Dr. actually say?

Pain scales - me

[ In Reply To ..]
Depends on who you work for or what the client wants.

I work for spine surgeons and pain management physicians directly, so yes I would expect you to transcribe 5/10. I have full editing privileges. However, if you work for an MTSO who expects strictly verbatim, I would leave as is.

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