HLA B27 how do I type this in diagnosis?

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! ...

Degenerative lateral meniscus tear? It sounds like he is saying degenerative. I have not heard of "degenerative" lateral meniscus tear. tia. ...

LEFT SHOULDER STRAIN CERVICAL AND TRAPEZIUS MYALGIA If so, would there be a comma put in? TIA. ...

s/l hypergolactanemia. The patient is on s/l promaxitine. ...

1. AIDS 2. Meningitis versus AIDS "sulfa patty"? ...

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. ...

If "elevated INR" is listed in the diagnosis, would INR be expanded to international normalized ratio? Thanks!! ...

would this be one or two? tia. DIAGNOSIS: STATUS POST CHEVRON BUNIONECTOMY, FOURTH HAMMERTOE CORRECTION ...

DIAGNOSES: 1. LEFT ANKLE SPRAIN 2. POSTERIOR TIBIAL TENDINOPATHY tia. ...

Axis III diagnosis, sounds like: History of left "corioma" of uncertain clinical significance. any help is appreciated. ...

Crush injury, right foot fracture of metatarsals tia. ...

When did this become okay? I got called on my last QA that spelling out CVA or MI in the diagnosis is a no-no. ...

nonunion of the fifth metatarsal, avulsion fracture should this be 2 separate diagnoses? tia. ...

Left shoulder impingement syndrome Small partial rotator cuff tear Tia. ...

Final Diagnosis..... ACE, ASA s/l "steve a" stable angina pectoris ...

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 ...

I am wondering if it is necessary to type out GAF in the diagnosis or to leave as is. Thanks for your advice. ...

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!! ...

9-year-old male with aggression, impulsivity and hyperactivity. Axis I - ADHD, combined type and s/l BMDD. (Need to expand BMDD.) ...

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. ...

HLA B27 how do I type this in diagnosis? - Kelley

do you have to expand it? sm - flybye

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