[ In Reply To ..]
3- to 4-/5 translates to "3 minus to 4 minus out of 5" and that's not what was dictated.
I Agree - Do Not Assume
[ In Reply To ..]
Do not assume he wants the minus there on the first number. You are much safer typing without it. Reader beware, and also, on an audit you would be relieved of what would may be be a critical error. Assuming the minus is a serious guess. I don't send those to QA, I type as dictated.
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! ...
Can someone tell me the correct way to type the Axis I through Axis V diagnoses part of an eval/progress note? I need to know the spacing, tabbing and punctuation. For example:
Axis I: 315.00 Reading disorder
Axis II: V71.09 No diagnosis on
Axis III:
Axis IV: &nbs ...
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. ...
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 ...
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 ...
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!! ...
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. ...
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 ...
When a physician dictates “It should be noted as well within the family history” and you are already typing the family history. Do you still type “It should be noted as well”? The doctor dictates this frequently. ...
Okay, I am sure I have heard this before but for whatever reason cannot seem to get it this time.....
he is saying..... "negative hawk sign, negative cochans sign"
Please help - can't take the time to search any more!
Thanks in advance for any help you can offer! ...
In pulmonary dictation, sounds like dictator is saying "lungs are known to have rales in the anterior and posterior....." But I know that is incorrect. Please help with the "are known" part. ...
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, ...
Doing EKG due to syncopal episode.
EKG is obtained because of a complaint of syncope showing a normal sinus rhythm, no s/l "current of entry."
Am I even hearing this right. I suspect I am not.
TIA!
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