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 have everything required except WordPerfect software. Would WP be compatible or cause problems if you have other software/platforms on your computer? I would think not, but things happen. Is this sofware even available anymore? Also wondering how the files would be uploaded back to facility. TIA ...
I have never run across this. Any ideas? Thank you.
He is concrete in his thinking, is goal-directed, but many of his goals are irrational, based on his history. ORIENTATIONAL ABILITY?? : His memory appears intact. ...
Word sounds like "Oh-jen-ing"
Doctor dictates: "He had a manic psychotic break with auditory hallucinations and (s/l) oh-jen-ing in the head. "
Thank you very much! ...
Hi,
In the list of discharge diagnoses the doc says "Psychiatric disorder s/l EN-OH-EFF or maybe IN-O-EFF." Does anyone know what this is? thanks in advance. ...
s/o "middle kingdom." Doctor dictates: "The patient is very basal ganglia driven and middle kingdom driven."
Thank you - I've looked in all my books and googled and can't find anything for "middle kingdom" driven. ...
Doctor dictates for the patient to "use the *relavan* technique to shift cognitive frame." (It almost sounds like "roll-a-van.").
Your help is much appreciated. Thank you! ...
I believe the words I need help with (which sound like "Crispy Slay") are the name of a test.
The doctor dictates the following: "It might be interesting to secure psychometrics and interesting to do an ASD workup, but at a bare minimum an IQ and achievement to see if there is a pattern on the scores. "Crispy Slay" was very mild."
Thank you very much for your help!
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He reports that he feels useless and worthless with sense of indifference towards self as well as others to the point he is unspontaneous and has no sense of feeling at times, suggestive of s/l *lasodymia.* The dictator is a mumbler so not sure if that is the correct beginning of the word or not. Thanks! ...
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? ...
Do I capitalize "Psychiatric Emergency Area" or just "Psychiatric Emergency" and not "area" ? I believe "emergency room" is not to be capitalized but I have seen where "Psychiatric Emergency Room" was capitalized. Thank You ! ...
I have 30-plus years of experience in transcription, but not medical. I am interested in getting into the psychological/psychiatric area of transcription. I have experience with psychological transcription, since I did work for a psychologist in the past transcribing evaluations and progress notes. I was wondering if anybody knows how to get into this area of transcription. Would I need to take a medical transcription course somewhere. Or would it be possible for me ...
I am doing an H and P and under the physical examination, dictator says -
PSYCHIATRIC: All pairs/pares intact.
Is 'pairs' correct? If not, any ideas?
Thanks in advance. ...
Greetings, I recently got a gig for Psychiatric clinic and I am a little confused as to the accepted formatting for DSM diagnoses under AXIS I... Here is what I have been doing, and it's different from examples I've seen online... I'm thinking I learned my current style from either CareerStep or working for Nuance; however, I'm not sure... My clinic doesn't really have any concrete formatting guidelines, but I want to be using best practices nonetheless. &nbs ...
In a psych eval treatment plan, the doctor states, "He will be on MSAS monitoring, minsui precautions, and alcohol withdrawal precautions."
What is minsui? how is it written? Is it an abbreviation, acronym? Looking at old reports I see about 6 different ways it has been edited. ...
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! ...
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. ...