consultation heading

I saw the patient for an extended neurological consultative on this day. Dr. Says Consultative twice in the report.. would you use that term? ...

Because of the combination of illnesses and particularly because of left arm weakness and s/l ("front coordination") as well as memory impairments she fells she cannot return to work doing clerical duties. ...

At the end of the report the doctor says Axis I -Adjustment disorder with anxiety, moderate in degree. Then he says "New paragraph, Psychogenic amnesia", then he says Axis II . Do I skip a line after Axis I, then write Psychogenic amnesia? How do I set that up? Please help, Thanks. ...

"The turbinates were pink and there was no mucopurulence. Afrin/________ was applied." It sounds like "PONT-uh-geen", but I've tried every spelling variation I can come up with. Thanks in advance! ...

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 ...

Dr. says Problem hashtag.....brain fart....do I number the problems? thanks. ...

working on a psychiatry consulation report and there are only a few headings dictated. "History of Present Illness", "Review of Past Medical Records", "Developmental Background", and "Diagnosis". Under "Review of Past Medical Records" there are several paragraphs dictated without headings and each one starts out with "Doctor (doctors name is cut off) diagnosed (or indicates) etc....., examples: Doctor diagnosed head injury, loss of consciousness, bilateral clavicle fractures, right scapula ...

On a consultation report, under the heading "past medical history" is there a specific order of sub headings according to the AHDI standards? ...

s/l Doctor with an accent is dictating Database: Chect x-ray slander cardiac silhouette. Please help. Thanks ...

The patient is quite ____pathic with an INR of 10. It almost sounds like the doc is saying overpathic or homopathic....TIA ...

Dictated problem list: Transcribed problem ...

See y'all in 6 minutes.... :) ...

AHDI has stated "that obvious headings that are not dictated may be inserted but this is not required." Does anyone know if this applicable in verbatim accounts? Has AHDI issued any new or different rules in regards to verbatim account? ...

He says it pretty clearly but I haven't been able to find anything resembling. Thanks for helping!! ...

The patient is referred with fever, chills and progressive shortness of breath with a history of IV drug abuse and alcoholism. The patient is a poorly-nourished 44-year-old Hispanic male in "s/l seria desperator" distress and agitated. Could the doctor mean severe respiratory distress? ...

Cannot make sense of what dr is dictating here...gave a few of the sentences before and after so you can get the context from this consultation report. Recurrent severe chest pain attributed to mitral valve prolapse increasing in frequency and intensity. History of global poor left ventricular function. Cannot rule out cardiomyopathy so I will be careful as regards negative. No trophic agents such as Inderal. Suggest that Inderal and Isordil be discontinued.&n ...

I have a couple of doctors who dictate without giving headings--I'm supposed to add these. What heading would I put "perineal exam" under in this report? He dictates it after the abdominal exam, but would that be the appropriate section to put this under? I thought of pelvic, but it really isn't a pelvic (female patient). ...

A friend suggested transcribing for the deaf, requires passing a 180-200 wpm test from conversation. Anyone done/doing this? It is a great consolation to get all of your support. MT Stars is wonderful to give us this opportunity. MQ never was able to maintain a professional forum. ...

We have just updated to Docqscribe 6.1 at our facility. Does anyone know if you can use the heading list function just for straight typing as we do not ASR. ...

I hear the doctor say Nature and Duration...Patient was admitted to ___ [PLACE]..... Is that right??? need serious help!! ...

I thought that DQS 6 was bad, but this 7.1 certainly topped that one. It seems to just randomly makes words headings whenever it feels like it. Just now, on a dictation clear as day, in the middle of a sentence, it decided that the word "the" was to be a heading. Why? ...

If you find missing text at the end of a sentence and a heading following, restore the heading ctl+shift+H and it usually is hidden under there..dont know why but you know they arent gonna fix it, so may as well try especially on those hard to figure out words. ...

Doc is describing telemery strip and says "tachycardia which appears to be multiple calachional tachycardia. Any ideas? thanks. ...

which of the 2 is correct: a.) Lasix 60 mg present by EMF b.)Lasix 60 mg present by EMS? ...

In transcribing a letter should Doctor's be capitalized: Dear Doctor's or doctors? ...

Thereafter he was seen at the student health center where evaluation was undertaken. ...

Gait testing is part of the neurological examination and should therefore go under that heading. From my perspective, healthcare document integrity should hold sway over account specs or doctor preferences. Too many doctors think all that matters is what they say or how they interpret what is said, which is total bunk. If that were true, we would all just start typing melanotic stools every time one of these medical geniuses dictates that because certainly there isn't a do ...

She brings with her a very good detailed consultation notes and other medical records from the Air Force including evaluation at the S/L FEZDA. ...

consultation heading - newmt

heading - not usually

Skin - MME

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