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.
...
I have heard this before, but I'm drawing a total blank and every way I spell it I keep getting spanish words or names of Saints back (argh)!
The full sentence reads: (the blank s/l inacious, ignatus, or something similar)
No significant chest pain or troubles breathing during exercise. No specific history of arrhythmias in the past. Does not appear to be _____. No history of stroke, diabetes, coronary artery disease, congestive heart failure.
Appreciate any help,
Thanks,
M ...
First time actually turned out to be social history, second time started out sort of sound like medical history which was basically noncontributory, but then turned into the review of systems, and now the third time may actually be the charm.
Now I've just got a lot of heavy breathing while he figures out what's next. Thank goodness my night is over in another hour or so. ...
Under "Review of Past Medical History" he says "Doctor diagnosed, etc." for several paragraphs. Is this a heading or does it need a colon after "diagnosed?" ...
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? ...
history or any actual conditions. Medication s/l Imodium lac D??? Possible that it is Imodium, s/l lac D (or maybe not Imodium at all and it is one word?) omeprozole is in list so he does have stomach issues. I'm stumped. Extremely fast dictator!!! ...
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 ...
I just remembered the Impact Room. I wonder how many trial-and-error programs we've been through over the past couple years. They must have a whole team of people who sit around all day and come up with one scheme after another, all of which are eventually scrapped. ...
used a 5-French Glide catheter and thru this passed a Spartacore wire into the popliteal artery past the stenosis.....Is this correct or am I losing my mind with these passed/past??? ...
I was going to go with I&Dd, but that doesn't look right. Or spelled out would be "The patient had an abscess that was incision and drained"? That doesn't look right either, but just unsure. ...
People are not doing a full listen/correction. There are some pretty blatant errors, and these errors are being repeated by subsequently dictating physicians who are obviously using other documents for information (as it should be). Blatant errors such as allergy to medications that don't even exit, blatant lab errors that are counter to some of the diagnoses.
I shamefully admit to not doing a full listen when I first started voice recognition was back in the beginning, but quickly noted ...