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Heading? - NewMT
Posted: Apr 22, 2010
This doctor describes the preop/postop diagnoses, type of anesthesia, and gives the surgeon's name (all of which I made separate headings for as it seemed he was dictating them). After the surgeon's name, he goes into a short description of the patient and a few physical exam findings as they pertain to the procedure. He does not dictate a heading or anything, although after his description of the patient, he dictates a new paragraph and a PROCEDURE heading. Should I put a heading for the patient description? It very easily could go under a PHYSICAL EXAMINATION heading, but I'm not sure if I should do this.
Thanks!
You need to check with your employer/client - sl
[ In Reply To ..]for all of this information. Where I work we have specific headings to use and we use "Indications for Procedure," but you need to check with them for this kind of specific question, i.e., whether they want headings added, is is verbatim, etc.
Headings - rqCMT
[ In Reply To ..]I agree that you should check into the account specifics before you add any headings, but if you are able to add headings, I would label this patient description as "Indications for Procedure" or "Clinical History." Hope this helps :)
sounds like an assignment - nm
[ In Reply To ..]nm
or test - ?
[ In Reply To ..]nm
Nope, neither. I finished my course already. - NewMT
[ In Reply To ..]nm
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