Psych diagnosis format question

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

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 ...

He says "was made n.p.o. and put on D5 half normal saline plus 20 of KCl at 78." Is this typed correctly? ...

Does anyone know where I could look at a rad report format online? I have AAMT Book of Style, but it does not show a format for radiology. All of the books online you have to buy. All I need is to know a format for a radiology report. ...

When typing combination medications should you put the dosage abbreviation after each medicaotin..... Example: hydrocodone 5 mg/325 mg or hydrocodone 5/325 mg???? Also, what if it is a medication combination that uses both mg and mcg? Example: 75 mg/200 mcg. I received a correction back from my boss and she had it 75/200 mg and, considering that part of the medication is mcg, i think that her correction is actually incorrect. ...

I posted about an hour ago under Gab Board. It is not there, and it was. Strange!!!! ...

A history and physical examination report. Doctor has already dictated information for EXTREMITIES subheading, but later dictates more info for same subheading. Should I combine second set of extremity info with first set of info? Thanks! ...

I am not sure how to format this medication and I think there might be a stumble also. Doctor says "... 2 tabs 125 mg 2 times p.o. t.i.d." Wonder whether I should edit out the either "2 tabs" or "2 times" as she does seem to correct herself. Any thoughts on this would be appreciated? Thanks ...

In a verbatim account: "patient is into" (doc lists medications)... Patient is into?? Very clearly said. "there are no labs available on the chart." (doc goes onto lists extensive lab results) Says also very clearly "this consultation was not necessary", however I am not sure if he is speaking to someone else, or if it is part of the dictation! I hear it clear as a bell, it just seems a snippy ending comment. I am going to type it out as I hear it, b ...

Doctor dictates: Ambien 10 mg q 9 p.m. Just making sure how the 'q 9 pm' is transcribed. Is it like this: q.9 p.m. or q.9. p.m.?? Not sure....any help would be appreciated. I am new to the job and want to make sure i do this correctly.Thanks ...

MD dictates C5-6... I usually change this to C5-C6, as it seems that is the more correct way. Should C5-6 be used? ...

Okay........ now don't laugh at this question. I recently had to pull up another transcriptionist's report, and came across something I've never seen before. I couldn't find the formatting this MT used anywhere else, so I am wondering if any of you have. I always type "90th percentile", "56th percentile", etc. when peds are talking about growth charts. This MT typed "90%tile", "53%tile", etc. Is that actu ...

Anyone know the correct way to format autopap? Is it AutoPAP, AutoPap, autoPAP, etc.? I can't find this in my references and I see it many ways online. TIA! ...

I know when there are more than 1 diagnoses, you list each one separately. How do you handle it when the dictator gives 4 separate diagnoses, then "etiology to be determined" at the end? List everything under 1 dx, or list "etiology to be determined" as a separate dx? Thanks. ...

SOCIAL HISTORYHalf a pack a day smoker. Alcohol: denies. Occupation: he is on disability due to chronic knee pain and an inability to work. Is it... Occupation: He is on disability... OR Occupation: he is on disability... There are several instances of this type in this report and I am not sure of the correct format.. thanks!! ...

How would you correctly write " he has 3 to 4 minus out of 5 in strength in bilateral hip flexors left worse than right." ...

Hi: For those MTs using the above, what do you all use? Thanks ...

Have I gone blind? I can't find the date format in the guidelines. Is it 01/01/2013 (like I've always done) or is it now 1/1/2013. I hate that they've changed the cranial nerves to 2-12. ...

The doctor dictated: CRP stable at 15.4 high. How would this be formatted? Would it be correct as CRP, stable at 15.4; high. ?? ...

I added all the subheadings. I am sure of the subheading Neurology and eyes. Any suggestions? Anything else look incorrect? I am still new to this. Thanks for the help. PHYSICAL EXAMINATION VITAL SIGNS: Blood pressure is 112/80, weight is 155 pounds, and height is 5 foot 6 inches. GENERAL APPEARANCE: Well-developed, well-nourished. No apparent distress. HEART: Regular rate and rhythm. No murmurs, carotids. No bruits bilaterally. NEUROLOGY: Orientation and language are normal. EYES: Fu ...

Anyone know what kind of system they use, word format, etc? And do they do a lot of VR? Thank you ...

shouldn't the word "hours" ALWAYS follow, i.e. 1345 hours? ...

I have 18 years experience in acute care transcription in just about everything except "pathology transcription." I have done a lot of ops of all kinds, oncology, neurology, cardiology, infectious disease, etc. Is Pathology transcription that different? I've done tumor staging, chemo protocols, just about any type of EEG, TEE, cath, radiology, etc. The reason I'm asking is I saw a job for a "Pathology transcriptionist" and I really believe I'm qualified with my knowledge, ...

Okay, i have a doc that is dicating pretty much an H&P but account specifics require SOAP format for all dicators. Would most everything go under subjective heading such as social history, family history, no known allergies, etc.? I know PE will go under objective, but would the ROS go under objective as well or subjective? 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. ...

Psych diagnosis format question - Going crazy

depends on your client profile. - see message

Same here also........nm - Cyndiee

Similar Messages: