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I transcribe micro-otoscopy

Posted By: OpMT on 2008-03-07
In Reply to: Is microtoscopy a valid word, used in ear surgery. nm - cc

Subject: I transcribe micro-otoscopy




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Otoscopy may be in there.
Subject: Otoscopy may be in there.


otoscopy
Subject: otoscopy

anyone have a good site related to hearing exams?


Pure tone testing demonstrated normal hearing for the right ear with a mild loss at 8 ka


wondering about the "ka"


is it possibly pneumatic otoscopy?
Subject: is it possibly pneumatic otoscopy?


micro?
Subject: micro?


Med s/l micro fen el ine (sm)
Subject: Med s/l micro fen el ine (sm)

Patient has hypertension and renal failure.  On Prograf, gemfibrozil and this medication.  No mention of transplant but with the Prograf I wonder.
micro shaft?
Subject: micro shaft?

nm
backwards u stands for micro
Subject: backwards u stands for micro


oops - IT'S Micro-K - sorry typo
Subject: oops - IT'S Micro-K - sorry typo


Maybe micro colonization for microscopic, or you could be
Subject: Maybe micro colonization for microscopic, or you could be

s
m = milli but u = micro ... there is a difference
Subject: m = milli but u = micro ... there is a difference

nm
Microforaminotomy or micro foraminotomy? nm
Subject: Microforaminotomy or micro foraminotomy? nm


Listen for Micro-Two needle holder nm
Subject: Listen for Micro-Two needle holder nm

.
Micro-K (K=potassium, usually dosed in mEq...a clue here) nm
Subject: Micro-K (K=potassium, usually dosed in mEq...a clue here) nm


micro and macro vascular complication
Subject: micro and macro vascular complication

google 'micro and macro complication diabetes mellitus' u will find answer
s/l micro spacsion of lateral jaws
Subject: s/l micro spacsion of lateral jaws

pt is having cosmetic jaw surgery and this is the procedure name
Hypo, hyper, macro, micro
I'm a long-time MT and I still have a problem telling hypo from hyper, hypothyroid from  hyperthyroid,  macro from micro, etc....unless it's very obvious from the content of the dictation which is a lot of times isn't.    Another difficulty is the lab values...it's hard to tell 15 or 50, 20 from 30.  I leave blanks and then I see where QA fills them in.  So, I don't know if my hearing is getting bad or if they or just guessing.  Or, they may have access to othe lab values from previous dictation.  So I'm just wondering if this is a common problem with other MT's. Maybe I need to have my hearing checked.
s/l Urine auto with micro - Has anyone heard of this?
Subject: s/l Urine auto with micro - Has anyone heard of this?


Pt having 'UA micro CNS' done....is CNS correct? Can't find reference, thx!
Subject: Pt having 'UA micro CNS' done....is CNS correct? Can't find reference, thx!

,,
Thanks, that was it. Now if he would quit using micro tapes, and get into this century! *sigh
Subject: Thanks, that was it. Now if he would quit using micro tapes, and get into this century! *sigh

:)
No, it is urinalysis (UA) and micro (microscopic) C and S which stands for culture and sensitivity.
Subject: No, it is urinalysis (UA) and micro (microscopic) C and S which stands for culture and sensitivity. nm

.


found OC-Auto MICRO 80 for fecal occult blood... =) NM
Subject: found OC-Auto MICRO 80 for fecal occult blood... =) NM

x
hyper (fast); hypo (slow); micro (small); macro (large)
Subject: hyper (fast); hypo (slow); micro (small); macro (large)

nm
Howell-Jolly bodies, seen on micro of RBCs, blue-black on Wright stain......fit???? NM
Subject: Howell-Jolly bodies, seen on micro of RBCs, blue-black on Wright stain......fit???? NM

nm
how do you transcribe this??
Subject: how do you transcribe this??

Doctor says * cardiac-wise the patient is doing well *    OR  * GI-wise he has had, blah blah blah blah...


I personally do not like the phrase * dash wise *   The only way around it, seems to me, is to add a bunch more words like * as far as his cardiac condition is concerned * which does not sound like the dictator.


What do you do? 


I would transcribe it as pus-like...nm
Subject: I would transcribe it as pus-like...nm

nm
I transcribe it like so..
Subject: I transcribe it like so..

Last, First, M.D.  But, I why?  I just do.  I have never had a complaint.  But, I'll transcribe Last, Reverend First (pastor), or Last, Sister First (nun). 


need to know the right way to transcribe....
Subject: need to know the right way to transcribe....

the doctor says---discharge medications and patient is still on---  Do I type it like this?  DISCHARGE MEDICATION AND PATIENT IS STILL ON:  or do I leave all caps and headings out and start a new paragraph?
Thank you-Is that how I transcribe it
Subject: Thank you-Is that how I transcribe it

too?
Tib-fib, how to transcribe it? Thanks. NM
Subject: Tib-fib, how to transcribe it? Thanks. NM


That's how I transcribe it
Subject: That's how I transcribe it


How would you transcribe this?
Subject: How would you transcribe this?

I'm doing a report on a hip arthroplasty, and the doctor says the Secur-Fit shell was driven into place in approximately 4520 parameter based off the sciatic notch.


Is that 45 x 20 or 45-20 or just as I have it above?  I'm stumped!


How would you transcribe this?
Subject: How would you transcribe this?


 I have a doctor who keeps saying axillosubclavian brachiocephalic vein as if this is one vein he is referring to, but I think it has to be two, so how would you transcribe it when he lists the procedures performed as:


1. Right axillosubclavian brachiocephalic vein mechanical venous thrombectomy using the Trellis-8 device.


2.  Right axillosubclavian brachiocephalic vein balloon angioplasty using a 10 mm x 4-cm long balloon followed by 6 mm x 4-cm long balloon followed by 7 mm x 4-cm long balloon.


3. Supervision and interpretation of fluoroscopy for performance of right axillosubclavian brachiocephalic vein mechanical thrombectomy, thrombolytic therapy and balloon angioplasty.


He doesn't pause between the words axillosubclavian and brachiocephalic vein.  Should there be a dash between the two or the word and?


 


how would you transcribe this
Subject: how would you transcribe this

8 instances of property damage level 1, 27 episodes of major noncompliance,
I transcribe it as
Subject: I transcribe it as

bilateral eye, bilateral knee replacement.
Transcribe 5.3
Subject: Transcribe 5.3

nm
Here is how I always transcribe it (sm)
Subject: Here is how I always transcribe it (sm)

Gram stain and gram-negative/gram-positive. 
I would transcribe it exactly as you have it. nm
Subject: I would transcribe it exactly as you have it. nm

.
If that is what he says, that is what you transcribe.
Subject: If that is what he says, that is what you transcribe.

x
How would you transcribe this? (SM)
Subject: How would you transcribe this? (SM)

"Sublingual nitroglycerin 0.4 mg "q.5's" p.r.n. for chest pain."

Is it okay to leave as is?


Yes, transcribe as 4.0 (sm)
Subject: Yes, transcribe as 4.0 (sm)

If dictated as "four point oh," you would transcribe as 4.0.

The zero after the decimal indicates the precision of the measurement. In lab values, you would need to transcribe as dictated in order to avoid "changing" the measure.

If you transcribed it as 4, the reader would wonder what you left off. A zero in other locations might be optional or up to the preference of the facility, but not this one.






how do you transcribe this?
Subject: how do you transcribe this?

We will need some ongoing p.r.n.'s of the MSIR.
gotten - when a doc says this, what do YOU transcribe?
Subject: gotten - when a doc says this, what do YOU transcribe?


That is how I transcribe it too.
Subject: That is how I transcribe it too.

We try not to use all caps even if the manufacturer uses all caps.
How do I transcribe this?
Subject: How do I transcribe this?

The patient will return in four weeks/weeks' time.
How would you transcribe this?
Subject: How would you transcribe this?

"The patietn is a 59-year-old who presented yesterday with shortness of breath and a hypertensive urgency of 120 over approximately 120 blood pressure."


Would the last part be "120/approximately 120 blood pressure" or just spell everything out like I have it?


TIA!


How would you transcribe this???
Subject: How would you transcribe this???

The doctor is saying that the wound was packed with 4 x 4s.  Would you transcribe it as 4 x 4s or 4 x 4????  TIA
Can someone tell me the correct way to transcribe
Subject: Can someone tell me the correct way to transcribe

A fib. I learned in school that it's A-fib. I used to type for cardio docs on my own account, and they wanted A fib. Stedman's Abbrv. has AFib, and another book has A Fib. Is there a "correct" or most preferred way? Thanks.
I transcribe: 5- to 6-mm nodule. NM
Subject: I transcribe: 5- to 6-mm nodule. NM

d
CORRECT WAY TO TRANSCRIBE
Subject: CORRECT WAY TO TRANSCRIBE

pt developing increasing pulmonary pressures in the 60s and 70s - or 60's and 70's?


Also, if doc dictates calcium one every day, calcium one q.d. or calcium q.d.? 


THANKS!!!


It's okay. I'd transcribe it as dictated. nm
Subject: It's okay. I'd transcribe it as dictated. nm

/
How do you transcribe this sentence?
Subject: How do you transcribe this sentence?

MRI scan has reportedly shown central herniation at C4, 5 and C5, 6