Probably talking about report physicians file with Motor Vehicle Dept - sm
Posted By: alm on 2007-11-13
In Reply to: stumped - ew
Subject: Probably talking about report physicians file with Motor Vehicle Dept - sm
When patient's have seizure disorder or passing out episodes, etc. most states want physicians to fill out a "Confidential Morbidity Report" (or name similar to that) and send to the DMV letting them know the patient has been diagnosed with condition that can cause loss of control of the vehicle -- did doctor say he counseled patient on not driving until seizures under control for x-amount of months or something like that?
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Patient in a motor vehicle accident with her tractor
Subject: Patient in a motor vehicle accident with her tractor
HEENT: There is no pain on palpation of her calvarial bones. Furthermore, there is no *s/l* "pain crepidence" or depression on palpation of the posterior spinous processes.
No hyphen in motor vehicle. Maybe driving a 4 x 4 with a roll bar
Subject: No hyphen in motor vehicle. Maybe driving a 4 x 4 with a roll bar
s
should dept. (neurology, neurosurgery) be capped in the body of a report?
Subject: should dept. (neurology, neurosurgery) be capped in the body of a report?
TIA
do you have a QA dept? If so, send it to them
Subject: do you have a QA dept? If so, send it to them
that's a poor, poor dictator FOR SURE.....I feel for ya....
Our job is not to police the physicians
Subject: Our job is not to police the physicians
on their dictation, just type what they say. How much time does one spend on figuring out how to "word" something they don't agree with?? Just type it and go on.
It is probably a dept name specific to
Subject: It is probably a dept name specific to
x
The hip. Other physicians have said "sorcele's sign
Subject: The hip. Other physicians have said "sorcele's sign
Maybe for your own accts, but not if you have a QA dept. that's going to pick you apart for any
Subject: Maybe for your own accts, but not if you have a QA dept. that's going to pick you apart for any
s
April - I was the exact same but worked a dept....
Subject: April - I was the exact same but worked a dept....
I worked in radiation oncology and then helped develop surgical oncology for a local hospital all during the 80s and got very familiar with all the terminology (but admit that I have trouble with all the new combo drugs that are always coming out).
It gets easier the longer you do it!!! 
LOL!! Have heard of critical care physicians though!!! nm
Subject: LOL!! Have heard of critical care physicians though!!! nm
seen "in" the clnic and dept "at" the hospital.
Subject: seen "in" the clnic and dept "at" the hospital.
x
Inspection of chest is okay...Physicians watch the rise and fall of
Subject: Inspection of chest is okay...Physicians watch the rise and fall of
No it does not - I went on to another file-then
Subject: No it does not - I went on to another file-then
privately-owned vehicle nm
Subject: privately-owned vehicle nm
nm
buccal vehicle route
Subject: buccal vehicle route
meaning absorbed through the oral mucosa
how about privately owned vehicle
Subject: how about privately owned vehicle
HIV file - terms used
Subject: HIV file - terms used
I'm working on a file about an HIV patient who also has a MAC infection. Under the "IMPRESSION", the dictation sounds like. Situation further complicated by disseminated MAC infection which led to s/l INCESNAL obstruction due to severe s/l MACROLIDED lymphadenitis. Improving s/l TEKEXIA.
Any help anyone could give me with any of those terms would be appreciated.
Thanks
Uh...a whole sentence might help us help you. Or where in the file is this? nm
Subject: Uh...a whole sentence might help us help you. Or where in the file is this? nm
s
s/l clipple file - sm
Subject: s/l clipple file - sm
Patient with a history of high-arched palate, velopharyngeal dysfunction, and *clipple file* who was recently with a chromosome 22q deletion.
Thanks for any help.
s/l *street* sleeping vehicle. Is this just another name for a trailor? nm Thanks
Subject: s/l *street* sleeping vehicle. Is this just another name for a trailor? nm Thanks
Listen to the voice file
Subject: Listen to the voice file
I keep all my voice files for at least three months. If I happen to get a QA tif back, I always go back and listen to the voice file and compare. Find out what the policy is on that account. I have found that some accounts expect corrections and others, right or wrong, expect verbatim transcription. I am blessed that the accounts that I edit and transcribe allow me to use good judgment.
Come to find out -- all I had to do was look through my expander file!!!
Subject: Come to find out -- all I had to do was look through my expander file!!!
nm
Starting sentences of a file
Subject: Starting sentences of a file
The patient is a ----and most usual entries as follows
-old accountant
-old active duty military personnel
-old administrator
-old advertising sales specialist
-old administrative assistant
-old African-American
-old airhostess
-old architectural conservator
-old astrophysics
-old assistant
-old attorney
-old aunt
-old auto technician
-old author
-old black
-old boy
-old board member
-old bank manager
-old banking person
-old business owner
-old bus driver
-old bartender
-old brought by
-old Caucasian
-old child
-old carpenter
-old construction worker
-old creative director
-old communications director
-old college professor
-old daughter
-old disabled
-old dancer
-old driver
-old emergency room physician
-old Egyptian
-old executive
-old female
-old financial advisor
-old girl
-old gentleman
-old Hispanic
-old Hassidic
-old homemaker
-old heating ventilation and air-conditioning mechanic
-old heavy equipment operator
-old hospitalist
-old industrial electrician
-old internist
-old infant
-old lady
-old laborer
-old left hand dominant
-old male
-old musician
-old medical secretary
-old nurse
-old obese
-old Oriental male
-old patient
-old physical therapist
-old right handed
-old retired
-old retiree
-old recovery room nurse
-old student
-old son
-old semiretired child case worker/nurse
-old technical writer
-old teacher
-old twin daughters
-old white
-old woman
-old well driller
-old young
Procedures: s/l can present my vehicle of venous doppler
Subject: Procedures: s/l can present my vehicle of venous doppler
Oxycodone sublingual or s/l bugle or vehicle route? Thanks. nm
Subject: Oxycodone sublingual or s/l bugle or vehicle route? Thanks. nm
x
Can you access file samples? They usually say procedures over
Subject: Can you access file samples? They usually say procedures over
s
I believe you're right. The file is a little warbled where she says it, so I'll flag it.
Subject: I believe you're right. The file is a little warbled where she says it, so I'll flag it.
Sounds like "Fuseman" file to remove heel spurs?
Subject: Sounds like "Fuseman" file to remove heel spurs?
x
between pain and improved where the voice file number and time is.
Subject: between pain and improved where the voice file number and time is.
Sucralfate (Carafate): Some physicians use rinses made from sucralfate, a barrier antacid, when need
Subject: Sucralfate (Carafate): Some physicians use rinses made from sucralfate, a barrier antacid, when needed. Other health care practitioners simply use the sucralfate pill dissolved in two or three teaspoons of water as a rinse
motor power 5/5 ;-) nm
Subject: motor power 5/5 ;-) nm
motor brace? sm
Subject: motor brace? sm
She finally got fitted for her s/l motor brace and is learning how to get this on and attached in a reasonable fashion. She is having to try to negotiate both wheelchair and a walker in order to fill all of her needs.
Dreft foot soaks. As in Dreft detergent. Older physicians recommend soaking feet in warm water
Subject: Dreft foot soaks. As in Dreft detergent. Older physicians recommend soaking feet in warm water
and Dreft - it soothes and softens and is gentle to the skin.
I keep hearing motor axenopathy
Subject: I keep hearing motor axenopathy
which is related to motor neuron disease. What comes up when I do a search is adenopathy but that "x" keeps being used. Could it be one word instead of the two words that I seem to hear?
Thanks.
Motor-sensory question
would this transcribed as Motor-sensory: 5/5 or as a clipped sentence Motor-sensory 5/5.
Under the physical examination
not sure about motor. I keep hearing moni uni. Thanks anyway.
Subject: not sure about motor. I keep hearing moni uni. Thanks anyway.
It could be motor unit but he is slurring and this is my first EMG so I better send with blanks. Better safe than sorry.
Fine motor skill?
Subject: Fine motor skill?
Neurosensory motor deficits,,,,nm
Subject: Neurosensory motor deficits,,,,nm
? distal motor latency
Subject: ? distal motor latency
Probably MOSIs...motor sign...check it first though...nm
Subject: Probably MOSIs...motor sign...check it first though...nm
nm
Clipped sentence. Motor/sensory 5/5. nm
Subject: Clipped sentence. Motor/sensory 5/5. nm
s
No focal motor or neurological deficits
Subject: No focal motor or neurological deficits
nm
guessing..associated diminution of motor strength? nm
Subject: guessing..associated diminution of motor strength? nm
.
motor and sensory s/l mentality intact
Subject: motor and sensory s/l mentality intact
5/5 sounds like normal motor strength...but sm
Subject: 5/5 sounds like normal motor strength...but sm
...i have no idea about your s/l... "overall motor strength"? there's also an OMA score (or OMAS)=Olerud & Molander Ankle Score but 5/5 power doesn't match that...?? =(
Motor Exam: s/l diminished tone, normal (sm)
Subject: Motor Exam: s/l diminished tone, normal (sm)
no atrophy.
the patient had a stroke and has no residual except for dysarthria. Can a motor exam show diminished tone and still be considered normal?
recruitment = ok. Also, could it be "normal motor unit waveforms"
Subject: recruitment = ok. Also, could it be "normal motor unit waveforms"
Is this correct- motor strength is 4+/5-. The more I read the BOS the more confused I am. TIA nm
Subject: Is this correct- motor strength is 4+/5-. The more I read the BOS the more confused I am. TIA nm
nm
I found a Bromage scale used for nerve/motor blocks. Maybe that's it.
Subject: I found a Bromage scale used for nerve/motor blocks. Maybe that's it.
Description of the Bromage score
Grade |
Criteria |
Degree of block |
I |
Free movement of legs and feet |
Nil (0%) |
II |
Just able to flex knees with free movement of feet |
Partial (33%) |
III |
Unable to flex knees, but with free movement of feet |
Almost complete (66%) |
IV |
Unable to move legs or feet |
Complete (100%) |
denervated *frontentials* seen with normal motor unit potentials.(EMG) Thanks. nm
Subject: denervated *frontentials* seen with normal motor unit potentials.(EMG) Thanks. nm
nm
Motor nerve study with "lace" dependent pattern. see message plz :)
Subject: Motor nerve study with "lace" dependent pattern. see message plz :)
Motor nerve conduction studies were notable for decreased amplitude in both upper and lower extremities in a lace dependent pattern.
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