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Culture and sensitivity would be right like you have it. You don't need to make a heading for it

Posted By: pc on 2008-02-09
In Reply to: It is mediolateral joint. If you are referring to two joints, it would be lines, otherwise, line. - pc

Subject: Culture and sensitivity would be right like you have it. You don't need to make a heading for it.




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UA C&S (culture and sensitivity). nm
Subject: UA C&S (culture and sensitivity). nm

.
C&S - culture and sensitivity?
Subject: C&S - culture and sensitivity?


May be C&S, culture and sensitivity.
Subject: May be C&S, culture and sensitivity.


C&S (culture and sensitivity)
Subject: C&S (culture and sensitivity)


nevermind, I believe C&S, culture and sensitivity. thank you
Subject: nevermind, I believe C&S, culture and sensitivity. thank you


did you mean for C&S? sputum for culture and sensitivity?
Subject: did you mean for C&S? sputum for culture and sensitivity?


C&S sputum? culture and sensitivity?
Subject: C&S sputum? culture and sensitivity?


C&S (culture and sensitivity) to rule out
Subject: C&S (culture and sensitivity) to rule out

Love to help!
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

.


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


Make INFORMANT a new heading.
Subject: Make INFORMANT a new heading.

CHIEF COMPLAINT:
Lump on the side of the neck.

INFORMANT:
Mother and patient.
I would make dg meds a heading, then type Patient is still... under it. nm
Subject: I would make dg meds a heading, then type Patient is still... under it. nm

x
candidiasis culture or anus culture? I'm just guessing here.
Subject: candidiasis culture or anus culture? I'm just guessing here.


how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm

xx
sensitivity
Subject: sensitivity

States culture is sensitive to quinolones and tobramycin, [____] to ceftazidime and cefepime -- blank s/l intermeded?
High sensitivity CPR..
Subject: High sensitivity CPR..

What does high sensitivity CPR stand for. I couldn't find anything only CRP. TIA.

Dr. says her high sensitivity CPR also was normal.
negative rod sensitivity or sensitivities?
Subject: negative rod sensitivity or sensitivities?


negative rod sensitivity or sensitives
Subject: negative rod sensitivity or sensitives

yes it is ESL--so do think it should be just sensitive? thanks for your help

Grew Proteus with s/l pan sensitivity? TIA
Subject: Grew Proteus with s/l pan sensitivity? TIA


PST - Potassium Sensitivity Test
Subject: PST - Potassium Sensitivity Test


LOOSE TESTING FOR SENSITIVITY?
Subject: LOOSE TESTING FOR SENSITIVITY?

THERE IS EDEMA SEEN IN ALL OF THE FINGERS WITH PINK COLORATION. THEN IT SOUNDS LIKE LOOSE TESTING FOR SENSITIVITY
Well, it has to do with sensitivity to skin touch, it seems.
Subject: Well, it has to do with sensitivity to skin touch, it seems.


maybe "cryesthesia" (sensitivity to cold) I think that
Subject: maybe "cryesthesia" (sensitivity to cold) I think that

makes sense.
The only thing I can find close is subtilise meaning to make senses more keen or make one's sense
Subject: The only thing I can find close is subtilise meaning to make senses more keen or make one's senses more acute?


I'm still listening and trying to fit it together to make any suggestions make sense.
Subject: I'm still listening and trying to fit it together to make any suggestions make sense.


cor is the heading. sm
Subject: cor is the heading. sm

Some say Cardiac:   S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.


 


What heading would you use?
Subject: What heading would you use?

Okay to add headings on OP report.  MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....


 


Thanks.


Under what heading would you SM
Subject: Under what heading would you SM

put inguinal hernia in a PE?  Would it be abdomen?


 


TIA


EKG can be a Heading
Subject: EKG can be a Heading

I would put under EKG alone as


 

EKG:  EKG today show no ST wave changes.
Heading?
Subject: Heading?

This is for a psych. consult.  After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.


I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records.  Past Medical History, yes, but not the other.  Any ideas?


Oops, used same heading, need help
Subject: Oops, used same heading, need help

Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".



Thanks


IV abbreviated in heading
Subject: IV abbreviated in heading

Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?


under abdomen heading
Subject: under abdomen heading

s/l "the PICC was created" or "the tic was created"


Angie


Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?

I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with

s
I think doc left heading out sm
Subject: I think doc left heading out sm

He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.


What would be asymmetrical here?


 


I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm

One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?

Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.

Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:

ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.

Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!

Needless to say, it stresses me out a bit. Any advice is definitely appreciated!

A lot of facilities use the heading
Subject: A lot of facilities use the heading

"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?

Just wondering under what physical exam heading other MTs put this finding under.

TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.

I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they

want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?

I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
Sorry, this should have been under heading Physical Examination.
Subject: Sorry, this should have been under heading Physical Examination.

 


In my opinion, should be spelled out in heading
Subject: In my opinion, should be spelled out in heading

nm
Not the OP, but a skin prep would be under a different heading
Subject: Not the OP, but a skin prep would be under a different heading

s
Heading in exam? COR: Cardiac etc.
Subject: Heading in exam? COR: Cardiac etc.


i would say Examination and Evaluation needs to be put as a heading.
Subject: i would say Examination and Evaluation needs to be put as a heading.

just my thoughts.
I use IMAGING as the heading for EKG, CAT scans, etc.
Subject: I use IMAGING as the heading for EKG, CAT scans, etc.


Hi, Julia, capitalize when used as heading, otherwise, SM
Subject: Hi, Julia, capitalize when used as heading, otherwise, SM

it is part of the sentence and should not be capizalized, somewhat like saying that patient is coming in for a complete physical exam, would not need to capitalize.


Not saying COR as a heading? for heart exam etc? nm
Subject: Not saying COR as a heading? for heart exam etc? nm