A community of 30,000 US Transcriptionist serving Medical Transcription Industry


Dr. dictates OB history and GYN history - hondamonster


Posted: Aug 20, 2011

Doctor dictates "OB history" and "GYN history" on a Discharge Summary, under Past Medical history. Should I spell out Obstetric and Gynecological is it okay to leave as dictated. I forgot. jn

leave it as is - junior

[ In Reply To ..]
.


Similar Messages:


Pt Has A History Of S/l Bowel-en-i-tis Bi-mo-sis. Pt Also Has A History Of Colon CA.
Jan 21, 2010

x   ...


Hyphens- 3-day-history Or 3 Day History?
Nov 01, 2010

3-day-history or 3 day history? ...


Above-listed History Or Above Listed History
Oct 19, 2009

I'm having a 4 am brain freeze and both/neither of these look correct. ...


Surgical History
Jun 08, 2010

In past surgical history - s/l andrognesis neuropathy ...


Where Is The History Of MT Recorded???
Dec 04, 2010

I need to find a credible source/s providing a detailed history of medical transcription - does anyone have any suggestions? I am a transcription supervisor writing a research paper on transcription for the degree program I'm currently in and the "history of" section I planned to include is proving pretty difficult to compose due to a severe lack of information. Thanks in advance for your suggestions. ...


A History Of S/l MSE Pulmonary
Sep 18, 2011

could be MSC or MSE pulmonary.  Thank you for any help. ...


3- To 4-year History
Apr 27, 2012

A 3- to 4-year history of diabetes. Are the hyphens correct here? I am totally blanking out. ...


History Lesson - What Are We
Oct 13, 2012

Article attached. We are waiting for permission to take massive action?  Not advocating violence, but please leave your damn jobs.  We deserve better.  There would be no MTSOs without MTs.  Don't you get it? They already stole our jobs, sent them overseas, created software to replace us, and we are fighting over scraps at slave wages.  Those who are happy being MTs, good, but $8-10 an hour doesn't cut it in my world.  That's not a living ...


Health History Question
Oct 19, 2009

Urology patient's health history.  Dr. says, "He does have a some foot s/l trap? that seemed to have resulted from some knee surgery..." Any ideas? TIA     ...


History Of Positive S/l Femovera
Nov 03, 2009

listing in past medical history. ...


Past History: Medications:
Dec 08, 2009

Seizure "s/l seizure in section" X 1. ...


History Of Migraine S/l Sythalgia
Feb 08, 2010

history of migraine s/l sythalgia.  I can't find this word anywhere.  I have checked sy, si, ci, and cy.  ...


Drug S/l Sol-pal-medow. Please Sm For Pt's History
Apr 13, 2010

CAD, HTN, DM, BPH, hypercholesterol. tinnitus and lumbago.  Thanks for any help.   ...


Past Medical History
Jun 26, 2010

Past medical history is given as below.  Not sure if the s/l goes where I put it or not since I don't know what he is talking about. Paraplegia secondary to spinal cord ischemia. status post stenting aortic aneurysm.  Iliac artery aneurysms bilaterally. Esophagitis. Umbilical hernia repair. transurethral resection of the prostate. Thoracic aortic stent s/l 6 of 18. Excisional debridement of sacral ulcer right hip ulceration. ...


Obstetrical History And Physical
Aug 10, 2010

I am typing on a patient who is having a vacuum delivery and the doc says:  "discussed plan of fetal monitoring, ficiapc.  Have you every heard of that and what do those letters stand for.  Thanks ...


Past Psychiatric History
Aug 11, 2010

ED is dictated several times a few of the instances are: Hospitalizations: 1. ED age 13 St. Clair Hospital Monroe 2. 15 years old ED November of that year. 4. 1996 3-week hospitalization in Racine was transferred to Mendota Mental Health Institute on an ED where she remained between May and September of 1996.   What does ED stand for? ...


S/l Dias History Of Retinopathy
Oct 06, 2010

pt has type II diabetes. regardign microvascular complications, doc states "patient had a dilateded eye exam in 2010 and a s/l dias history of retinopathy."     any ideas?? ...


Drug Allergies To Lix-o-lin And Lo-zel. Pt Has A History Of
Nov 15, 2010

x ...


History Of DVT - Possibility Of Suppression?
Dec 09, 2010

 The knee actually looks very good today, but to ____ cover the hematoma that we had cultured back as there is a possibility of suppression.  Her calf has a long history of DVT. Should it be:  "cover the hematoma that we had cultured back as there is a possibility of suppression in her calf.  Has a long history of DVT. Does suppression make sense in this instance?  This is a new doctor and dictation is very muffled.  Just can't make sense out of this.   ...


Pt Has A History Of S/l War-strom's Disease?
Jul 21, 2011

x ...


Providing Salary History
Feb 02, 2012

I am looking for work and notice some companies ask for a salary history.  I feel uncomfortable about this, not sure why, but I think it is to their advantage to know this info, not mine.  In my case, I worked for my last company for 5 years with one raise and the companies before that are ancient history.  How would one handle this.  I am not even sure if I have that info on some of my companies.  Why do they want this info? ...


In GYN History: Pt Did Use S/l S A P's For 5 To 7 Years In Her Youth.
Nov 21, 2012

Her husband has had a vasectomy, and she does not use oral contraceptive pills.  She did use "SAPs" for 5 to 7 years in the past and has never used hormone replacement therapy. ...


Work History (Medquist)
Jan 22, 2013

How can I show proof of employment with MedQuist from back in the mid 1990s to early 2000s?  I need exact dates of employment; unfortunately, I don't have a personal record and cannot remember.  Thanks for any help with this. ...


H&P Past Medical History
Sep 16, 2013

The patient underwent left *av facial accretion*.  I don't have anything else to help figure it out and I can't verify it.   ...


Help! Doc Says Patient Has History Of S/l Avolutional (sm)
Sep 03, 2014

movements likely due to essential tremor.  I know volutional is voluntary but A-volution has to do with behavior.  Patient is well controlled so then I thought maybe "abolition of" but just not sure. ...


S/l Keratin Malaysia... Just In Family History NFI
Jan 25, 2010

In the family history, just says "Father has s/l keratin malaysia" malashea... any ideas?  thank you ...


Drug Help - S/l Methanacol. Pt Has A History Of DM, Retardation, Please Sm
Mar 10, 2010

blood clots, psoriasis, OA, CAD, diverticulitis, glaucoma, CHF and hypothyroidism.  Thanks!   ...


History Of S/l ADM In The Proximal Ascending Colon
Sep 27, 2010

I cannot find this abbreviation on Google or in Stedman's.  Full sentence: "History of (s/l "ADM") in his proximal ascending colon with slowly spontaneous oozing." Atypical diabetes mellitus doesn't seem right in this context. ...


There Is No *presop* Like Nausea. There Is No History Of Stroke?? Thanks. Nm
Jan 19, 2011

nm ...


History Of GI Bleed S/l Dulaphoid Lesion?
May 23, 2011

This is just listed as part of the history so I do not have much to go on otherwise. ...