My question is about headings. Is it principle diagnosis or principal diagnosis? I have typed it "principle" for 10 years. The person doing our QA says it is principal. Has this changed?
thanks ...
I don't know if I am just not thinking straight or if there is reason I cannot find these. Under diagnoses, doc says the pt has ARA(?), DM, car-pul-mon-ali, P slash atrial fibrillation....
Seriously, I cannot find ARA, no sign of carpulmonali, or P/atrial fibillation. Any ideas at all? I am going to continue to think and search. TIA for any help! ...
Urogenital Distress Inventory is the urologic term I know but this is listed as a diagnosis and has to be written out naturally. Anyone know it? Thanks. ...
I cannot make sense of this diagnosis. This is exactly what the doctor says. Any help would be appreciated. TIA. The word with may also be incorrect.
EXOSTOSIS MEDIAL MALLEOLUS WITH TALUS AFTER ANKLE REPLACEMENT ...
Hi -
Can't seem to find any mention of this in BOS3, but can someone tell me whether I should be using "GI" or "gastrointestinal" in a preoperative diagnosis? I seem to remember in school being told to leave GI as is when in the ROS but seem to be drawing a blank on this one! Thanks in advance!! ...
Pruritus ani. I Googled it to make sure I had everything spelled right. The first thing that came up was "pruritus ani = itchy butt". Got a good laugh out of that. I think one of my dogs has that problem. ...
This is a young male patient who came to the ER with tachycardia and chest pain that eventually resolved and who was taking amphetamines (although he lied and said he wasn't and then wouldn't admit it). So at the end, the doc says "Diagnosis: Chest pain s/l NOF or NOS." I don't know what this stands for. Any ideas? ...
I am now totally confused. I've always been told the rule of thumb is that if there IS no #2, then there is no #1 to create a list. It should simply be Diagnosis: yada
I have a dictator that for some unknown reason kept dictating
Diagnosis:
1. UTI:
A) Resolved after antibiotics.
No number #2 so i just did not even number this, but I got it back QA'd , am I losing it or have been doing this wrong all along?
Thanks much for the input. ...
Struggling to understand a heading in a Discharge Summary. It's used where the diagnoses are being listed, but it doesn't sound like either diagnosis/diagnoses or assessment. Any ideas? ...
Does anyone have a good understanding/explanation of 3M software resequencing the principal procedure on certain operations? Hysterectomies were one, has anyone else experienced this? Do you change it back? ...
The doctor is saying the following ....
Twenty units of Pitocin were administered postpartum. No pocalisis (????) was administered.
I am not sure what the bold word is, it just sounds like this. ...