Dictated: Eyes: Extraocular muscles intact. He has bilateral Marcus Aurelius. Tympanic membranes are okay.
Transcribed: Eyes: Extraocular muscles intact. He has bilateral arcus senilis. Tympanic membranes are okay.
first time a Roman empirer has made an appearance in my transcription! This was not even VR! ...
Pediatric pulmonology report. In the physical examination, HEENT, he states "the patient has a normal ____. The tympanic membranes are normal bilaterally."
s/l he is saying "sinavia atruamatic" but I can't find anything relating either to the sinuses or even using synovia.
Thanks for the help. ...
Patient has pain in the right submandibular triangle. It is recommended that he have a "sialadenosubmandibular duct endoscopy." Is there such a term? Thanks. ...
I think my problem with this issue is that once you are "caught" by QA/QC and given a 1.0 deduction (by which I mean I had the universally accepted HEENT and they heard HENT, thus I was docked 1.0 for that), I now must either listen carefully to determine if they are saying HENT or HEENT, then put one or the other, then still have a chance that my reviewer will give me the error because they hear something different.
If there is obviously ears and eyes that one is easy, but oftentimes it DOES s ...
From now on, I am blanking HEENT/HENT any time I am not 100%, absolutely, positively sure of what the doctor says. Especially if they don't say anything at all (which is the usual).
This is utter ridiculousness and I am not going to risk a QA (or QC or whatever it is!)'s subjective opinion about whether a dictator said (or meant) one E or two!
What's next? If they only dictate a finding on the right lung, do we have to label it as "RIGHT LUNG:" instead of ...
When I requested reversal over getting gigged on this I spelled my thoughts out pretty thoroughly but don't know how far up the chain of holiness that goes.
Has anyone else shot off their opinions on this? Hoping if we get enough of us to make an issue they might reverse this idiotic ruling.
...
I've heard of palpable cords plenty of times when examining the extremities, but this time under HEENT, doc says "His mucous membranes are moist. His temples had no *s/l palpable cords* and nontender to palpation. Pupils equal, round, and reactive..."
Is this correct? ...
Doing a report for a counseling and recovery center. Dr. says....
AIIMS exam showed mild involuntary movement of upper extremities and t____ assessment.
Is it AIMS exam or Ames exam. I am also unsure of the blank, it sounds like it starts with the letter T. Thank you Thank you in advance! ...
Pt with squamous cell carcinoma of the nasal cavity with upper lip and hard palate invasion. He has an artificial nose.
On examination of the patient's oral mucosa, there are no visible lesions on the floor of mouth or buccal mucosa. He does have a healed "forax transposition" in placed on his upper hard palate. Upon examination of his nasal cavity, he does have a well-healed stomal site where his previous nose was.
I'm stumped :/ ...
He's clearly saying Ears: NTM bilaterally ..... and ears and TM bilaterally makes no sense anyway. Anyone know what that acronym could stand for?? in regard to ears/heent ??? I can't find it anywhere. ...
External exam, pupillary exam, and slitlamp examination of the anterior segment are normal both eyes intact, all tension is normal both eyes. Undilated funduscopic examination with a 90-diopter revealed a question of mild nerve s/l "fiber alla" edema. ...