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s/l ID or ID8 urine culture. for impression and plan

Posted By: me again on 2007-10-11
In Reply to:

Subject: s/l ID or ID8 urine culture. for impression and plan




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leukocyte esterase test, urine C&S = urine culture and sensitivity
Subject: leukocyte esterase test, urine C&S = urine culture and sensitivity


urine culture
Subject: urine culture

urine culture that has shown sl-BRE
Need help with lab/urine culture.
Subject: Need help with lab/urine culture.

Culture was done of her urine and it revealed less than 10,000 s/l colonies per mill. Is colonies correct? Would she mean per million?

urine culture for TB?
Subject: urine culture for TB?

I first thought he said this: Probably I need to obtain the urine for a kidney culture.  Then when I listened this morning it sounded like TB?  Is this correct? 
Urine C and S, as in culture and sensitivities??
Subject: Urine C and S, as in culture and sensitivities??

nm
Urine culture positive for s/l Perfidantious too-ahh-tee? nm
Subject: Urine culture positive for s/l Perfidantious too-ahh-tee? nm

nm
urine culture bacteria count- sm
Subject: urine culture bacteria count- sm

dr. says the culture showed 10-25 Klebsiella.  I wanted verification whether I'm correct in assuming that she means 10,000-25,000.  Those are usually the kind of numbers that I hear.
Urine culture revealed ൒ to the 5th" E. coli.
Subject: Urine culture revealed ൒ to the 5th" E. coli.

n/m
ID would be infectious disease, maybe consult? and urine culture? nm
Subject: ID would be infectious disease, maybe consult? and urine culture? nm

.
s/l urine culture positive for purdious and she was given a treatment of Cipro
Subject: s/l urine culture positive for purdious and she was given a treatment of Cipro


s/ pt'sl urine culture has found to have 25-50,000 colonies of morganalamogondy
Subject: s/ pt'sl urine culture has found to have 25-50,000 colonies of morganalamogondy

help.......
Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?

Sorry, tried to help. Have a nice weekend.
candidiasis culture or anus culture? I'm just guessing here.
Subject: candidiasis culture or anus culture? I'm just guessing here.


http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html
Subject: http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html

http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html
urine cultures, GC, chlamydia, urine s/l SMV.nm
Subject: urine cultures, GC, chlamydia, urine s/l SMV.nm

xx
Help with IMPRESSION
Subject: Help with IMPRESSION

Should this be dictated like this?


1.  Hyponatremia, rule out subdural hematoma. 


OR


1. Hyponatremia.


2.  Rule out subdural hematoma.


impression
Subject: impression

type it with a semicolon in between.
Impression
Subject: Impression

Hi Shirl -

Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.

Some usual headings in a radiology report are:

CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.

FINDINGS: or RESULTS:

IMPRESSION: or OPINION:

Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression

In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression

Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm


IMPRESSION prob
Subject: IMPRESSION prob

I have a problem under impression ...


"D: IMPRESSION:  Occipital neuralgia probable acute gastroenteritis"


question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?


NOTE: but the dictator did not dictate any numbering.... 


Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not?  TIA!
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or

the a new section after it.

Thanks :)
Impression - hypertension
Subject: Impression - hypertension

This is under impression on a history and physical examination.


It is a numbered list.


[Sodiunduradine] is hypertension.


Any suggestions would be great!


It was under the impression section
Subject: It was under the impression section

I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.

Pt with mental retardation.
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.


it's impression and lung markings....
Subject: it's impression and lung markings....


No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.


impression, SP - status post
Subject: impression, SP - status post

nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression

Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression.  Help appreciated.



Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm


Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM

ss
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.


Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm


impression: bronchiolitis s/l sublets? or other process
Subject: impression: bronchiolitis s/l sublets? or other process


Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon


I was under the impression it was JCAH mandated to write ml instead of cc. NM
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM


Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"


Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM

(s/l shrowd ligament rupture).
Plan
Subject: Plan

CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.


I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.


Plan help please!
Subject: Plan help please!

  I am a new, and need some help.  after the doctor says plan he lists the medications he has prescribed.  He does not number them and I am used to them saying medications and then listing (1, 2, 3)   Do they usual do that?  Should I leave it like he says it?  Example: 


PLAN:


Ecotrin 1 p.o. b.i.d. with meals.  Keflex 500 mg p.o. q.i.d. for 4 days..  Follow-upl with me within the next 10 days.


 


thanks!


Plan help please!
Subject: Plan help please!

That all depends on the QA person reviewing the report.

I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).

I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.


Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you


Do you have to have a plan?
Subject: Do you have to have a plan?

Where I work, if they don't say "plan", they don't get a "plan".


That's what I plan to do.
Subject: That's what I plan to do.

I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Subject: nevermind it's 'off' axis. He repeated it in the impression much more clearly!


I was under the impression that VAC is an acronym for vacuum-assisted closure.
Subject: I was under the impression that VAC is an acronym for vacuum-assisted closure.

Both Stedmans acronyms and Tessier surgical have it as VAC.
saw the patient, and the impression was s/l brass sediment impaction?(
Subject: saw the patient, and the impression was s/l brass sediment impaction?(


Firstly, would it be Impression: (instead of "colon") Negative mammography...
Subject: Firstly, would it be Impression: (instead of "colon") Negative mammography...