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aaaahh, my previous note should be SM!

Posted By: nm on 2009-05-27
In Reply to: brain right as well, looks like they mean same thing - nm

Subject: aaaahh, my previous note should be SM!




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Found previous note. It was Sigma...nm
Subject: Found previous note. It was Sigma...nm

nm
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych


No previous MI. Tx anyway! nm
Subject: No previous MI. Tx anyway! nm

xx
You might not like this one, but I would go by what QA said on the previous report. This way you hav
Subject: You might not like this one, but I would go by what QA said on the previous report. This way you have verification in writing of why you chose to keep it this way in case you are questioned on your choice of interpretation. I know we are looking for common sense but we are transcriptions and as we know that is not even close to always being the case in MD dictations.


could it be part of previous ??
Subject: could it be part of previous ??

could it be the dosing of the med before and you think he is going to the next number in the list? The "million" part is making me question this. Otherwise I have no idea. I hope you find your answer!
a previous post
Subject: a previous post

had this same sentence and it was "early satiety"
PS to clarify my previous post
Subject: PS to clarify my previous post

2 drugs:


s/l Cadawa NHCTC; I think it's for hypertension or hyperlipidemia.


s/l Rocethrin. For lesions? Could also be a pain med.


TIA!


 


I took this from a previous post about eponyms... sm
Subject: I took this from a previous post about eponyms... sm

According to BOS

eponyms

"While the use of the possessive form with eponyms remains acceptible, AAMT's preference is generally to drop the possessive form.

Apgar score, Babinski sign, Down syndrome, Gram stain, Hodgkin lymphoma.

Sometimes an awkward construction calls for use of the possessive form. This patient suffers from Hodgkin's."


just a thought..how about no change to previous?
Subject: just a thought..how about no change to previous?


Previous surgery for s/l lat pulley. TIA nm
Subject: Previous surgery for s/l lat pulley. TIA nm


did the link show up with the previous message?
Subject: did the link show up with the previous message?


Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
Subject: Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,

any ideas? 


Thanks


Here's a link to a previous MTStars post
Subject: Here's a link to a previous MTStars post

on this same question.  Is this an ENT account?  The best thing would be see if you can get verification from the account, might be some name they have for their own conconction of Maalox, Benadryl and Xylocaine.  I've seen plenty of things misspelled in reports, even standards handed out by an account itself...
no, doesn't make sense....previous does
Subject: no, doesn't make sense....previous does

is this dictator an ESL? 


prior history of left shoulder pain?


previous history of left shoulder pain?


 


Found it in a previous dictation - it is Toronto.
Subject: Found it in a previous dictation - it is Toronto.


OOPS DISREGARD PREVIOUS THIS IS WAY IT IS WRITTEN?
Subject: OOPS DISREGARD PREVIOUS THIS IS WAY IT IS WRITTEN?

A trigger point injection at the right gluteus maximus trigger point was performed using mixture of 2 mL 2% Xylocaine and 1 mL 40 mg per mL Depo-Medrol.
Maybe referring to a stitch from the previous fistula??
Subject: Maybe referring to a stitch from the previous fistula??

x
Agree with previous poster. NEVER GUESS
Subject: Agree with previous poster. NEVER GUESS

x
I was able to locate a previous report which has 1, so I'll go with that
Subject: I was able to locate a previous report which has 1, so I'll go with that


pt with previous respiratory burns on prednisone and now s/l zo air. ?? nm
Subject: pt with previous respiratory burns on prednisone and now s/l zo air. ?? nm


Can you check a sample of doctor's previous
Subject: Can you check a sample of doctor's previous

c
patient with previous cesarean section..sm
Subject: patient with previous cesarean section..sm

preterm premature ruptured membranes, history of cervical prolapse and suspected s/l "cor amniotic"  (but her voice trails off at the end so have no idea what she is saying)
previous s/l attisoning syndrome secondary to steroid use
Subject: previous s/l attisoning syndrome secondary to steroid use


elevated liver functions, previous cholecystectomy.
Subject: elevated liver functions, previous cholecystectomy.

CT showed (S/L) ''normobilia''??  (have looked everywhere and cannot find--thanks for any help.)


capitalization rule after the previous word was a number.
Subject: capitalization rule after the previous word was a number.

how to capitalize the first letter of a new sentence if the last word in the previous sentence was a number?
He is referring to restless legs (from previous) but clearly says "skitchy". Ideas?
Subject: He is referring to restless legs (from previous) but clearly says "skitchy". Ideas?


previous s/l "graft trostomy tube placement" along with COPD
Subject: previous s/l "graft trostomy tube placement" along with COPD

previous s/l graft trostomy tube placement" along with COPD
He's saying bowstrung - I located a previous report where another doctor calls it a
Subject: He's saying bowstrung - I located a previous report where another doctor calls it a

nm
Hi - thanks for trying. I was lucky and found a previous report for patient and it is TBSO.
Subject: Hi - thanks for trying. I was lucky and found a previous report for patient and it is TBSO.

nm
Previous surgery includes lateral release of the s/l D&ACL reconstruction as well as shoulder.
Subject: Previous surgery includes lateral release of the s/l D&ACL reconstruction as well as shoulder.


Breast exam - She does have asymmetry in both breasts from previous s/l brain ansatangias. please sm
Subject: Breast exam - She does have asymmetry in both breasts from previous s/l brain ansatangias. please sm

I know that makes no sense at all but that's what it sounds like. This doctor is from Puerto rico. Up until this point, she has been pretty clear. Thanks for any help
Ophthalmology consult, this elderly gentleman has evidence of previous s/l a. phaci...the only
Subject: Ophthalmology consult, this elderly gentleman has evidence of previous s/l a. phaci...the only

thing that comes to my mind is phacoemulsification. The doc dictating this is so old and slurs so much that he should probably be retired. Any ideas anyone?
There is evidence of previous caput costae, left thorax with good bony healings
Subject: There is evidence of previous caput costae, left thorax with good bony healings


noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy

Just wondering if there is any general rule about transcribing noteworthy.


Also, status post; status-post.


 


Thank you.


 


Op note ref. SM
Subject: Op note ref. SM

http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note

? pulse ox 99% on room air which is normal per ______ interpretation.


 


ER note thanks
Subject: ER note thanks

Thanks, practically sure it was per the ER physician reading. So, will be ready for next time!

At the end of OP note, he says
Subject: At the end of OP note, he says

what sounds like "mick" instrument and needle count. 


On another, says "sponge, _____and instrument" and that sounds like "lab".  Any clues are appreciated.  Thank you!


OP note help please sm...
Subject: OP note help please sm...

mild (s/l-fibulations-) with changes on the surface of the condyle
Of note..... I want
Subject: Of note..... I want

to thank everyone so much for all the help I have received on this website since I have become an MT.  Bless everyone of you.  I hope one day to help those also asking questions as you all have me.


Op note
Subject: Op note

Dictator says: Local Xylocaine 1% anesthesia 'arfate' cannulated.

What is the 'a' word?
me again - same op note :(
Subject: me again - same op note :(

The wound was irrigated and rough edges were S/L RASSED. 
op note help
Subject: op note help

Using an up-biting basket and a S/L 405 shaver a medial meniscectomy was performed.


 


TIA!


OP NOTE HELP
Subject: OP NOTE HELP

The iliotibial band was then split inline with the incision and retracted anteriorly and posteriorly with a _____ bow.  s/l charming.....


 


The procedure is a cemented bipolar hemiarthroplasty left hip. 


OP NOTE STILL
Subject: OP NOTE STILL

Should have went further in the note...sorry...another blank is


Attention was directed to the proximal femur, which was prepared with a box-cutting chisel, _____ canal finder and a trochanteric router  this sounds like "chauney"


 


ESL help with op note
Subject: ESL help with op note

She says:  With forceps and a S/L barpotta knife the lesion was excised.  (This is excision of a lid nodule). 
have another on this same note - sm
Subject: have another on this same note - sm

Bilateral elbow rheumatoid arthritis. The left side is more advanced with (s/l)'spectus articulusdamage than appears on the right side
op note help
Subject: op note help

This is an excision of a breast nodule.  Two questions:


1. The area was prepped with s/l Cloraprep


2. The needle was grasped with an S/L Alice clamp


See note below
Subject: See note below

 


This is the context of the report.  It sounds just like Waddellian.  He says this quite a bit and it stumps me every time....


PSYCHIATRIC:  The patient was alert and oriented x3 with a somewhat depressed and scattered mood, being very jumpy and quickly agitated by minimal movements or pressures in various areas such as supporting the leg while doing musculoskeletal motor examination for neurologic examination.  The patient definitely showed some ____________________ symptoms through our examination.  When the idea of psychiatric help in this manner was brought up in this case, the patient seemed almost excited to know this was a coming event.


op note help
Subject: op note help

This is a partial medial meniscectomy and synovectomy.


large s/l type 1 plica present - is type 1 correct?


This was resected back to a stable configuration using an s/l oslite shaver or 8 inch shaver (he mumbles) ???


op note help
Subject: op note help

This is for an amputation of the left hallux. 


Upon induction of IV sedtion a total of 10 ml of 0.5% Marcaine plain was infiltrated in a S/L Mayo block type fashion.


Mayo block???