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She will follow up with me(v)/will be seen in followup(n); will have a follow-up visit (adj) [2008-08-25]
Subject: She will follow up with me(v)/will be seen in followup(n); will have a follow-up visit (adj) x
Pediatric Arm Sling - ProCare Healthcare Bear ? [2008-08-22]
Subject: Pediatric Arm Sling - ProCare Healthcare Bear ?
tamoxifen AFA 81 mg daily. [2008-08-13]
Subject: tamoxifen AFA 81 mg daily. This is in regards to treatment of a woman with breast cancer. I cannot decipher if the doctor is saying tamoxifen AFA 81 mg daily or something else. According to my references the usual dose of tamoxifen is 25 mg daily so possibly the doctor is saying due to tamoxifen AFA but then what medication would sound like AFA? Please help!
Listed medication - s/l aceta-kil XL 30 mg daily [2008-08-11]
Subject: Listed medication - s/l aceta-kil XL 30 mg daily Patient is 92 and comes in for hip fracture. This is one of her regular medications. Past medical history significant for CVA, chronic shortness of breath, dyslipidemia, hypothyroidism, ischemic colitis, colon polyps, hyperkalemia, acute renal failure, CLL.
Drain was removed at this first postop visit- discontinued makes the most sense. Thanks! [2008-07-15]
Subject: Drain was removed at this first postop visit- discontinued makes the most sense. Thanks!
in pediatric HEENT exam, s/l "bilcolocephalic?" [2008-07-12]
Subject: in pediatric HEENT exam, s/l HEENT: (s/l Bilcolocephalic.) His conjunctivae are without erythema or mattering. He seems to visually track to light and person well. He has a symmetric bilateral red reflex.
pediatric cardiology - Norwood s/l SANOMONIFICATION?? [2008-06-19]
Subject: pediatric cardiology - Norwood s/l SANOMONIFICATION?? A 14-month-old with complex congenital heart disease, basically hyperplastic left heart syndrome with a NorwoodSONOMONIFICATION? initially at birth and status post bidirectional Glenn.
The patient did have a s/l UDM at the last visit that was positive for opiates. [2008-06-09]
Subject: The patient did have a s/l UDM at the last visit that was positive for opiates. Is UDM correct? If so what is spelled out?
Pediatric echocardiogram - [2008-05-29]
Subject: Pediatric echocardiogram - ...peak gradient acoss there is approximately sl 90 tour?
Pediatric echocardiogram - [2008-05-29]
Subject: Pediatric echocardiogram - ...peak gradient acoss there is approximately sl 90 tour?
Pediatric rheum visit. Med s/l soyametatine/solumetatine 400 mg daily sm [2008-05-16]
Subject: Pediatric rheum visit. Med s/l soyametatine/solumetatine 400 mg daily sm I'm not sure what the med is for, but child has PFAPA syndrome. On my s/l, I hear the end better than the beginning, hence the two different beginnings.
Thanks!
Boy with fevers and pain (rheum. visit). He does not have any *tempwella* with ... sm [2008-05-11]
Subject: Boy with fevers and pain (rheum. visit). He does not have any *tempwella* with ... sm ... the fevers or the presumed joint pains. He does not seem to have any morning stiffness.
Thanks.
drug name: S/L enterlogen 250 daily ?? [2008-05-09]
Subject: drug name: S/L enterlogen 250 daily ??
Daily use of antibacterial soaps or Burow's soaks should be utilized. Intralesional or systemic [2008-05-04]
Subject: Daily use of antibacterial soaps or Burow's soaks should be utilized. Intralesional or systemic
Pediatric exam. Has anyone heard this - [2008-04-26]
Subject: Pediatric exam. Has anyone heard this - Examination of a 2-year-old, doctor says resist exam appropriate. Very clear.
pediatric w/ diarrhea- mother has been "giving him soy milk, water, and [s/l propel]"- any ide [2008-04-21]
Subject: pediatric w/ diarrhea- mother has been "giving him soy milk, water, and [s/l propel]"- any ideas? nm nm
Thought it had more to do with her sources of information on the patient prior to initial visit. nm [2008-04-17]
Subject: Thought it had more to do with her sources of information on the patient prior to initial visit. nm x
drug: S/L mepofed 4 mg daily [2008-04-15]
Subject: drug: S/L mepofed 4 mg daily
medication s/l voltrin 100 mg daily. patient has glaucoma, diabetes and arthritis. Thanks! nm [2008-04-10]
Subject: medication s/l voltrin 100 mg daily. patient has glaucoma, diabetes and arthritis. Thanks! nm
whoops, meant 60 mcg daily. Any ideas? [2008-04-07]
Subject: whoops, meant 60 mcg daily. Any ideas?
Should read: Amitiza 24 mcg (not mg) twice daily (no msg) [2008-04-03]
Subject: Should read: Amitiza 24 mcg (not mg) twice daily (no msg)
Aspirin s/l grains or drains 5 daily. sm [2008-04-03]
Subject: Aspirin s/l grains or drains 5 daily. sm 1. Non-insulin-dependent diabetes.
2. ASCVD status post CABG.
3. Status post CVA without neurologic deficit, except for some mild dysphagia.
4. Obstructive cerebrovascular disease.
Given dipyridamole 50 mg t.i.d. He is to continue with s/l s/l aspirin grains/drains 5 daily.
Thanks!
med sounds like: Ateza (a-tee-za) 24 mg twice daily. [2008-04-02]
Subject: med sounds like: Ateza (a-tee-za) 24 mg twice daily. Any ideas?
medication s/l cory-zox-e-zone? 500 mg po four times daily (doesnt say what its for) [2008-03-28]
Subject: medication s/l cory-zox-e-zone? 500 mg po four times daily (doesnt say what its for)
Office visit H&P- Thanks! nm [2008-03-17]
Subject: Office visit H&P- Thanks! nm
help please [2008-08-26]
Subject: help please For overactive bladder he is taking s/l Sentor TR 60 mg orally daily. Thank you!!
She will follow up with me(v)/will be seen in followup(n); will have a follow-up visit (adj) [2008-08-25]
Subject: She will follow up with me(v)/will be seen in followup(n); will have a follow-up visit (adj) x
Medication [2008-08-25]
Subject: Medication s/l Practicam 20 mg daily. TIA.
Pediatric Arm Sling - ProCare Healthcare Bear ? [2008-08-22]
Subject: Pediatric Arm Sling - ProCare Healthcare Bear ?
Per AAMT-BOS2 [2008-08-18]
Subject: Per AAMT-BOS2 classification systems
Systematic arrangements into groups or classes.
See: cancer classifications, cardiology, obstetrics, and orthopedics.
Some classification systems use arabic numerals and others call for roman. In some systems there is no agreement on the use of roman versus arabic numerals. There is a trend away from the use of roman numerals, and generally speaking, the preference is for using arabic numerals unless it is documented that roman numerals are required. Several classification systems are listed below; check appropriate references for additional guidance.
Apgar score
Assessment of newborn's condition in which pulse, breathing, color, tone, and reflex irritability are each rated 0, 1, or 2, at one minute and five minutes after birth. Each set of ratings is totaled, and both totals are reported. Named after Virginia Apgar, MD.
Do not confuse with APGAR questionnaire for family assessment.
Use initial capital only.
Express ratings with arabic numerals.
Write out the numbers related to minutes, so that attention is drawn to the scores and confusion is avoided.
Apgars 7 and 9 at one and five minutes.
Ballard scale
A scoring system for assessing the gestational age of infants based on neuromuscular and physical maturity. Scores are converted to gestational age (in weeks).
Express in arabic numerals.
score age (weeks)
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
burn classifications
Burns are described as 1st, 2nd, 3rd, and 4th degree, according to burn depth.
AAMT recommends dropping the hyphen in the adjective form (e.g., 1st degree burn), though use of the hyphen is acceptable.
Expressing ordinals as numerals is preferred to writing them out: 1st, 2nd, 3rd, and 4th degree burns, not first, second, third, and fourth degree burns.
Rule of Nines: Formula, based on multiples of 9, for determining percentage of burned body surface. This formula does not apply to children because a child's head is disproportionately large.
head 9%
each arm 9%
each leg 18%
anterior trunk 18%
posterior trunk 18%
perineum 1%
Berkow formula: Rule of Nines adjusted for a patient's age. Assigns a higher percentage to a child's head, which is larger than an adult's head in proportion to its body.
Catterall hip score
Rating system for Legg-Perthes disease (pediatric avascular necrosis of the femoral head).
Use roman numerals I (no findings) through IV (involvement of entire femoral head).
Child classification of hepatic risk criteria
Classification of operative risk.
Capitalize Child (eponymic term), lowercase class, and capitalize the letter that follows.
Child class A
Child class B
Child class C
decubitus ulcers
Decubitus ulcers are classified using roman numerals from stage I (nonblanchable erythema of intact skin) through stage IV (full-thickness skin loss with extensive tissue destruction).
diabetes mellitus classifications
See: diabetes mellitus
Epworth Sleepiness Scale
Measures daytime sleepiness on a scale of 1 to 24. Use arabic numerals.
Less than 8: Normal sleep function
8-10: Mild sleepiness
11-15: Moderate sleepiness
16-20: Severe sleepiness
21-24: Excessive sleepiness
The patient's Epworth Sleepiness Scale is 16.
fracture classifications
See: orthopedics
French scale
Sizing system for catheters, sounds, and other tubular instruments. Each unit is approximately 0.33 mm in diameter.
Express in arabic numerals.
Precede by # or No. if the word number is dictated.
Do not lowercase French.
5-French catheter
#5-French catheter
catheter, size 5 French
Keep in mind that French is linked to diameter size and is not the eponymic name of an instrument. Thus, it is a 15-French catheter, not a French catheter, size 15.
Glasgow coma scale
Describes level of consciousness of patients with head injuries by testing the patient's ability to respond to verbal, motor, and sensory stimulation.
Each parameter is scored on a scale of 1 through 5, then totals are added together to indicate level of consciousness. (Glasgow refers to Glasgow, Scotland.)
score level of consciousness
14 or 15 normal
7 or less coma
3 or less brain death
global assessment of functioning (GAF) scale
A scale used by mental health professionals to assess an individual's overall psychological functioning. Typically reported in a psychiatric diagnosis as axis V.
Use arabic numerals 0 (inadequate information) through 100 (superior functioning in a wide range of activities).
Axis V GAF = 60 Flat affect.
See: diagnosis for a more complete discussion of psychiatric diagnoses.
global assessment of relational functioning (GARF) scale
This scale is used by mental health professionals to measure an overall functioning of a family or other ongoing relationship. Use arabic numerals from 0 (inadequate information) to 100 (relational unit functioning satisfactorily from self-report of participants and from perspectives of observers).
GVHD grading system
Graft-versus-host disease.
Use arabic numerals 1 (mild) through 4 (severe), placed on the line directly after the abbreviation (no space). May also be expressed as clinical grade 1 through 4.
GVHD1 or GVHD clinical grade 1
GVHD2 or GVHD clinical grade 2
GVHD3 or GVHD clinical grade 3
GVHD4 or GVHD clinical grade 4
Harvard criteria for brain death
In addition to body temperature equal to or higher than 32°C and the absence of central nervous system depressants, all of the following criteria must be met in order to establish brain death.
unreceptivity and unresponsiveness
no movement or breathing
no reflexes
flat electroencephalogram (confirmatory)
Hunt and Hess neurological classification
Classifies prognosis of patients with hemorrhage.
Write out and lowercase grade; do not abbreviate.
Use arabic numerals 1 through 4.
grade 3
Kurtzke disability score
Two-part scoring system to evaluate patients with multiple sclerosis.
Part one evaluates functional systems (pyramidal, cerebellar, brain stem, sensory, bowel and bladder, visual, mental, and other).
Part two is a disability status scale from 0 to 10.
Use arabic numerals.
magnitude scale
Measures earthquake magnitude. A one-unit increase on the scale equals a tenfold increase in ground motion.
Express with arabic numerals and decimal point.
She was injured in an earthquake measuring 6.6 magnitude.
Mallampati-Samsoon classification of airway
With the patient seated upright, mouth opened as wide as possible and tongue protruding, the anesthesiologist examines the airway—soft palate, tonsillar fauces, tonsillar pillars, and uvula—to evaluate the ease or difficulty of intubation: class I (easy intubation) through class IV (nearly impossible intubation).
Lowercase class and use roman numerals.
NYHA classification of cardiac failure
Use roman numerals I (asymptomatic) through IV (severe cardiac failure).
See: cardiology
Outerbridge scale
Assesses damage in chondromalacia patellae.
Lowercase grade.
Use arabic numerals 1 (minimal) through 4 (excessive).
Diagnosis: Chondromalacia patellae, grade 3.
physical status classification
A classification developed by the American Society of Anesthesiologists to classify a patient's risk of complications from surgery.
Lowercase class and use arabic numerals (1 through 5). The capital letter E is added to indicate an emergency operation.
class 1E
Rancho Los Amigos cognitive function scale
Neurologic assessment tool. Levels I through VIII are written with roman numerals.
I no response
II generalized response to stimulation
III localized response to stimuli
IV confused and agitated behavior
V confused with inappropriate behavior (nonagitated)
VI confused but appropriate behavior
VII automatic and appropriate behavior
VIII purposeful and appropriate behavior
social and occupational functioning assessment scale (SOFAS)
The SOFAS is an instrument used by mental health professionals to assess an individual's social and occupational functioning only.
See: global assessment of functioning (GAF) scale above
Use arabic numerals from 0 (inadequate information) through 100 (superior functioning in a wide range of activities).
TIMI system
See: cardiology terminology
trauma score
Scoring system that measures systolic blood pressure, respiratory rate and expansion, capillary refill, eye opening, and verbal and motor responses on a scale of 2 through 16. Score predicts injury severity and probability of survival.
Use arabic numerals.
s/l mesalinth [2008-08-16]
Subject: s/l mesalinth I have a new doc and can't figure out what medication he is dictate, sounds like mesalinth 50 mg po daily. Any ideas?
tamoxifen AFA 81 mg daily. [2008-08-13]
Subject: tamoxifen AFA 81 mg daily. This is in regards to treatment of a woman with breast cancer. I cannot decipher if the doctor is saying tamoxifen AFA 81 mg daily or something else. According to my references the usual dose of tamoxifen is 25 mg daily so possibly the doctor is saying due to tamoxifen AFA but then what medication would sound like AFA? Please help!
Care-Clens- Keri-Clens? Help [2008-08-12]
Subject: Care-Clens- Keri-Clens? Help S/l Cariclens, Kericlens to the left shin daily
no dermatological condition stated [2008-08-12]
Subject: no dermatological condition stated It is to be applied to the shin daily, then followed by Panafil ointment daily.
Listed medication - s/l aceta-kil XL 30 mg daily [2008-08-11]
Subject: Listed medication - s/l aceta-kil XL 30 mg daily Patient is 92 and comes in for hip fracture. This is one of her regular medications. Past medical history significant for CVA, chronic shortness of breath, dyslipidemia, hypothyroidism, ischemic colitis, colon polyps, hyperkalemia, acute renal failure, CLL.
med s/l cyclomidrol [2008-07-31]
Subject: med s/l cyclomidrol It The med s/l cyclomidrol ophthalmic drops. Any help - I can't even find anything close on Rxlist.com
word help [2008-07-25]
Subject: word help This patient presents to us status post dorsal intercarpal ligament injury. We are going to have this patient go back into a thumb spica cast. This will be four weeks of immobilization. At that visit, we will examine her again s/l and attach the ligament to see if we need to hold it for another two weeks at that point.
qs [2008-07-24]
Subject: qs We are not to use abbreviations. How would you transcribe what the doc dictates.
He dictates: The patient was discharged to home with Omnicef prescription 125 mg/5 cc, 3 cc orally twice daily x7 days, dispensed qs.
myasthenia gravis [2008-07-22]
Subject: myasthenia gravis The patient has myasthenia gravis.Medications: Synthroid 0.15 mg p.o. daily, s/l fanfadil 30 cc after meals, 1-2 times per day, potassium supplements.
Medication dosages, QA marking wrong both ways! [2008-07-18]
Subject: Medication dosages, QA marking wrong both ways! Good afternoon everyone. I When typing medication dosages, I have always transcribed them the same way for the last 12-1/2 years. For example, Lortab 5 mg q.4h. p.r.n. pain.
I have worked for the same company for a little over two years now and have neverhad QA say anything about this untillast month, whenI got a QA audit marking it off and changing it to Lortab 5 mg q. 4h. p.r.n. (with a space between the q. and the 4h.) I thought okay, maybe Iall lthis time and a new QA person picked up on it. It happens, no big deal.
So, I started transcribing it their waywith the space, as in q. 4h. and didnmore aboutit. Yesterday, I get another audit. This time, I get dinged for typing it the way they wanted it the last audit q. 4h. with the space with a note stating it should be q.4h. with no space (the way I had been typing it).
Now, I know they have been messing with all of the MTs big time lately, making changes daily from everything to hours, pay, policies, and procedures for vacation, days off, etc. You name it, theyto fire some of us or drive us to the point of insanity until we quit, but despite the games, I still want to make sure I If I
Sorry for the long, drawn out post, but I Now, I Thank you for taking the time to read my question and rant. I would appreciate any and all opinions on how you all transcribe this!
Some ideas ... [2008-07-17]
Subject: Some ideas ... Go to google.com and type in suntuf. You will get 8900 hits. See if any of those look like a medical word to you.
If not, then you have almost done your due diligence in terms of searching on your own.
Now, open up your reference books (of which you should have several), and pour through them, looking for something that makes sense in the context of the patient's visit and history. If you find nothing, then you have almost completed the due diligence for which you're responsible before you ask for help.
Now, go to Google and type in all of the words you think it sounds like. If none of those come up as medical terms (on reputable sites) that make sense in the patient's history and reason for visit, and sound exactly like what the doctor is saying, you have completed the due diligence you're responsible for in order to post here with your question.
Please, only post your question once. You may follow up to replies on that one post, but do not continue to post the same question as separate threads. If no one answers your question to your liking, it is time to either ask your supervisor or leave a blank. Repeating the same question over and over will not lead to an answer - it will lead to the frustration of people trying to help you.
If this is a term the doctor says repeatedly, you need to ask your supervisor for examples of that doctor's report. In it, you will most likely find exactly what you're looking for, and you will also have samples for further questions you may have.
If not, leave a blank and ask whomever QAs your work for the answer to your blank.
The word help board is not here to type your reports for you. It is here after you have exhausted all other means of finding an answer. Otherwise, it not only appears as if you're taking the help of others for granted, you're expecting someone else to do your work for you.
Good luck finding the words you're looking for. I'm sure we're all curious to hear what the real phrase was, once you are given the answer to your blank. Please keep us updated.
Thanks!
slang [2008-07-15]
Subject: slang Dr. says Penrose s/l dc
Patient had his Penrose drain removed at the visit. I Any ideas?
TIA
sm [2008-07-15]
Subject: sm dc'd usually means either discontinued or discharged - depending on the context of the sentence. This one sounds like it would be discontinued but not certain if it was removed at the last visit. ?
Drain was removed at this first postop visit- discontinued makes the most sense. Thanks! [2008-07-15]
Subject: Drain was removed at this first postop visit- discontinued makes the most sense. Thanks!
in pediatric HEENT exam, s/l "bilcolocephalic?" [2008-07-12]
Subject: in pediatric HEENT exam, s/l HEENT: (s/l Bilcolocephalic.) His conjunctivae are without erythema or mattering. He seems to visually track to light and person well. He has a symmetric bilateral red reflex.
Anyone ever heard of s/l *thalastizole* therapy? (see message) [2008-07-11]
Subject: Anyone ever heard of s/l *thalastizole* therapy? (see message) Patient has peripheral vascular disease with right lower extremity claudication. Part of doctorrecommendations: Continue aspirin therapy daily. Given symptomatic dyspnea, will avoid (s/l) *thalastizole* therapy for the time being.
not sure if this will help much.... [2008-07-09]
Subject: not sure if this will help much.... the patientlisted __________, Singulair, and nasal sprays as daily medications.
it is a medicine that the patient took with claritin also.
not much information by this sentence, but maybe it will help [2008-07-09]
Subject: not much information by this sentence, but maybe it will help the patientlisted __________, Singulair, and nasal sprays as daily medications.
it is a medicine that the patient took with Claritin also.
Medication help needed. Please see message for context [2008-07-08]
Subject: Medication help needed. Please see message for context Pt had infected burn on his leg. He has been using s/l neo-peer-sin ointment prescribed at his last visit.
Pt with diabetic foot ulcer - med question; s/m. [2008-07-06]
Subject: Pt with diabetic foot ulcer - med question; s/m. The patient would use the Ocugel daily with 4 x 4s, Kerlix, Ace wrap, and change daily. (Thank you!!)
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