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Vital Signs Question - Rainstorm
Posted: Jul 18, 2010
Sometimes one of my doctors will just state the numbers when giving vital signs. Just wonder how some of you handle this?
vital signs - MT67
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I put them where they go, some of my docs like the headings and some just want the initial, for example, T: xx. But quite often all I get are the numbers. HTH :)
What I've always done - Oracle
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Is write the appropriate 'word' to go without it, so 123/62, 72, 16 would become blood pressure 123/62, pulse 72, and respirations 16. I have never been dinged for it. In addition, one of the accounts I'm on now requires that it be done. Obviously, account specs supercede anything I say, but if there is nothing specified, I would add the words for clarity. Again, that's just what an old-timer would do.
However the client wants. Where I work we transcribe - j
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it as dictated, if not given, we don't type it.
Please help.....I know I've heard this before but am drawing a complete blank....On examination, temperature 97, blood pressure 139/73, heart rate 89, respiratory rate 16. She is 93% s/l on rule _______. She runs this and General Appearance together and I just can't get it. Thank you so much for any help. ...
She could also be saying any other phonetically similar letters.
There is nothing else listed under the vitals, so its probably a generic "all negative" term. (Afebrile, Stable Vital Signs...something else)
This dictator is one of those where the who PE is abbreviations. Thanks ...
Since when are vital signs separated by semicolons? Did I miss something???
My feedback -
VITAL SIGNS: Blood pressure is 183/111; pulse is 88;88, respiratory rate 18;18, temperature 97;97, oxygen 96%.96. ...
Not putting in the temperature at all, no matter how clear it is dictated. Messing up the sequence of the rest and the measurements..this is beyond annoying ...
This Indian lady sounds like on the vital signs part as saying "No cathalication, upper landmine", ? Can't find anything similar to cathalication and upper landmines. Any help would be appreciated!
...
Clearly s/l "for far." I thought maybe he was saying 4th floor, but doesn't sound that way at all. Could it be some kind of specialized nursing staff for rehab? An excellent dictator - I just can't figure this bit out! ...
Anyone know anything about Vital Lines out of Bogart, Georgia? Their website says they accept resumes, but there is nothing else. I am assuming they would probably have Independent Contractor positions. Wondering if anyone else has heard of them before I send in my resume.
Thanks.
...
Persistent cough with mild progressive dyspnea with advanced mass-like consolidation with (cut sign, cussign, cufsine) noted within right lung parenchyma.
This is an english-speaking doctor, very clear... ...
No past reports to look this up and doctor does not repeat in the report.
"# weeks post s/l table signs, left index"
The only thing it mentions about the index is it has a hypertrophic scar.
Any ideas? Thank you
avulsion injury laceration ...
Does anyone else have this rule with transcription? I was told a while back and cannot remember where I heard it that you are not to use plus or minus signs anymore unless using them for actual math. For example, positive bowel sounds instead of + bowel sounds, or +2 pedal edema should be plus-2 pedal edema. ...
I have read the conversations here with such deep compassion for the fear and hopelessness most are experiencing in this transition from proud profession to extinction. From my cocoon of full benefit hospital system position, I still deeply empathized with my fellow MTs in distress. I have the sense that I will soon join your ranks and would like to ask what are the signs that your hospital/service is preparing to "save money" by throwing their dedicated employees into the giant cess ...
Hi everyone, new to this forum. I work for a hospital and a lot of us are getting a bad vibe lately, we work from home but we are noticing little things happening, we keep losing our connections, Joblister keeps disconnecting and we are told the firewall is being updated. Was wondering if anyone noticed little things like this before they were outsourced. Thank you ...
I have a doctor who, under the neurological exam section, says, Deep tendon reflexes were intact. Tinel's and <s/l sickelseen> signs were both negative. Romberg was negative..."
Thanks to anyone who might have a clue! ...
These all happened to me:
Your interview keeps getting rescheduled, and rescheduled.
The interviewer walks out into the lobby to greet you, and appears disappointed/less-than-enthused.
Your interview is conducted not just by one or two people, but by an intimidating group of 4 or 5 glowering, power-suit-clad men & women, in a huge board room. Donald Trump begins to come to mind. ("You're NOT hired!")
Worse, your interview is conducted in a cubbyhole under t ...
She's not available on email, she's not signed into Spark and she doesn't answer her phone, or she's off on vacation. This happens day in, day out. ...
When a doc dictates lets say "negative Kernig" versus stating "negative Kernig sign" will I transcribe it as "negative Kernigs" or "negative Kernig's" ...
and is it mandatory??? MModal Tech and my cable company say it is causing me to lag in a major way...so I kind of dont use it anymore...not that anyone knows yet!!! just curious ...
Equally performs NUMBER FOUR SIGNS with assistance of his upper extremities.
Could this be putting the ankle in the back of the opposite knee to create a "4" sign? Never heard of this... ...
Took a tour of my local hospital last night for a continuing ed class and we were in Medical Records. She brought up outsourcing transcription and I asked who they use and she said "Signs, Seinz, or something that sounds like that?" ...