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Depends on your acct specs. nm

Posted By: Just me on 2007-09-11
In Reply to: Should EKG be expanded in Assessment? - Jori

Subject: Depends on your acct specs. nm

s


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I would, but I'm a rebel. Check acct. specs re verbatim. n/m
Subject: I would, but I'm a rebel. Check acct. specs re verbatim. n/m


It depends on your company's specs.
Subject: It depends on your company's specs.

.
guess it depends on specs..
Subject: guess it depends on specs..

We're not allowed to do that even with surgery. Plus, docs usually say, for instance, 2:30 position or at 2:30.
depends on whether or not it's a verbatim acct
Subject: depends on whether or not it's a verbatim acct


Right.....it depends on the acct.....mine wants the "c"
Subject: Right.....it depends on the acct.....mine wants the "c"

xx
depends, is it verbatim acct? If not, change it to
Subject: depends, is it verbatim acct? If not, change it to


I never use orthopaedics and it is not allowed by my work specs..so it depends on your company! nm
Subject: I never use orthopaedics and it is not allowed by my work specs..so it depends on your company! nm

nm
Depends on your company specs. Okay for me to use with my company. nm
Subject: Depends on your company specs. Okay for me to use with my company. nm

nm
Unless it's in their specs (for some reason)...
Subject: Unless it's in their specs (for some reason)...

gram-negative is with a lowercase "g"
format that to your accts specs (sm)
Subject: format that to your accts specs (sm)

a.m., AM, whatever your acct likes! LOL
I would be careful there. My account specs are different. nm
Subject: I would be careful there. My account specs are different. nm

x
New acct: SM
Subject: New acct: SM

Okay, been away from transcribing general practice for while.  Dictator is running a marathon here.  I have a couple of questions.


 


Patient is s/l attentionly and alert plus and cooperative. 


for the life of me I am not hearing what I want to hear...awake, alert, oriented times three.  etc. 


 


Also, in PE:  Lymphatic system s/l neither anterior and posterior cervical chain.


agree, especially if client really stresses this in specs
Subject: agree, especially if client really stresses this in specs

/
verbatim acct help
Subject: verbatim acct help

General surgeon talking about frozen section pathologic exam of squamous cell carcinoma lesion. First frozen section came back with positive margins so he went back to excise a second specimen which he submitted S/L "on fos" with the new margin up. This is a verbatim account and this dictator is on 100% QA (all reports) since he is so SPECIAL. I referenced the other reports in his MD data base and found "en Fos" which would have been put there by QA before the report was signed off to the hospital. I can't find this anywhere and was wondering if anybody has a clue?
New doc, new acct, ideas?
Subject: New doc, new acct, ideas?

Does this sentence make sense to any of you?  This is a disability and he it sounds like he is saying jaw?  but why would that be under cardiorespiratory?


CARDIO-RESPIRATORY: He has no signs of cardiac abnormalities, no claudication, no chest pain, or numbness of the jaw. 


Could it be something else?  Please give it a try! 


Small C? Not anywhere I've ever seen. Subscript 2, but many formats/specs don't allow for that
Subject: Small C? Not anywhere I've ever seen. Subscript 2, but many formats/specs don't allow for that. nm

nm
my main acct is verbatim,
Subject: my main acct is verbatim,

and we are told we can change sentence structure...however, whether i'm told that or not, i correct to proper English, including tenses, etc. Verbatim is never really absolutely verbatim, no matter what anyone says. You must use common sense. The bottom line is to be careful that you never change the intended meaning.
New GI acct. Does anyone have any helpful links? TIA
Subject: New GI acct. Does anyone have any helpful links? TIA


Only if your acct wants it changed. Not KS here, but our docs
Subject: Only if your acct wants it changed. Not KS here, but our docs

s
Thx. I am helping on new acct for holidays, and not doing too well :(
Subject: Thx. I am helping on new acct for holidays, and not doing too well :(


pin ... does your acct require you to adhere to dangerous
Subject: pin ... does your acct require you to adhere to dangerous

just asking


Depend if the doctor says it and it is a verbatim acct.
Subject: Depend if the doctor says it and it is a verbatim acct.

x
s/l neruo forminal is this correct ? Sorry started a new acct today and unsure if one word or two.
Subject: s/l neruo forminal is this correct ? Sorry started a new acct today and unsure if one word or two.

x


Muffin is correct. My children's hosp. acct uses McMuffin & muffin nm
Subject: Muffin is correct. My children's hosp. acct uses McMuffin & muffin nm

nm
Depends....
Subject: Depends....

I have an ortho doc that insists on using it the way the dictionary shows it, follow-up. He is not of old school, very young and a professor. Says it is his biggest pet peeve to see it ever used without the hyphen, and doesn't care much for BOS rules.

So, when in doubt, I do it exactly the way the dictator wants it no matter what I think.
think it depends on where you are...sm
Subject: think it depends on where you are...sm

like colour/color, theatre/theater, etc. i think "hiccups" is more common in usa.
Depends...sm
Subject: Depends...sm

It honestly depends on your employer's guidelines. Check with your Editor/QA staff. Sometimes there is just no way to make a doc make sense on paper without changing everything around and so it's easier just to really type verbatim; some docs only need a tweak here and there, so you really need to find out what 'verbatim' means as applied to the account you are working on.
Depends
Subject: Depends

One nurse's notes
Two (or more) nurses' notes
depends on the doc
Subject: depends on the doc

I worked for a chiropractor who wanted it disc but every other type of doc I've done wanted it disk
depends on how much.....
Subject: depends on how much.....

leeway you have.  With the comma there, it looks strange.  If you have to transcribe verbatim, I would put a hyphen....thus, * New patient - arm pain...*  If you have more leeway you could make a sentence * This is a new patient with a chief complaint of arm pain *.  If that is too much and looks like you are padding lines, then you could try just * New patient with arm pain *
depends on what it is...
Subject: depends on what it is...

a stroke could be evolving or completed....
Depends -- sm
Subject: Depends -- sm

I think it depends on the state where you want the information.

type for a hospital in Washington state, and they have a state licensure site with just about everything in the same site (i.e. physicians and physical therapists, nurses, etc. )

On the other hand, Arizona has only the doctors in its doctor database, and you have go to the Arizona physical therapist site to search for them.

Generally, when I first start typing a particular state, it takes a while to build up a set of search sites, but as I find them I add them to my favorites and then create a category for that state, so I don't have to search so much the next time.

Have a great day.
it depends
Subject: it depends

It depends on if it is modifying something.

The diameter of the wound is 1 cm.

There is a 2-cm length length discrepancy.

That's how I decide whether to hyphenate or not. On plural numbers, you can something tell if it should be hyphenated if it is said singular - i.e. six centimeters = 6 cm or six centimeter difference 6-cm difference

does that help?
Depends
Subject: Depends

Depends on the client preference. Generally, cardiorenal is accepted. Otherwise, it would be cardiac renal. I think he was just tripping.
Depends where you are from.. :-)
Subject: Depends where you are from.. :-)


Depends...
Subject: Depends...

I think it would depend on the specifics for that account - the hospital I work for would want it to read: 110 to 120 over 70 systolic.


Depends
Subject: Depends

I would not number unless doc states or your MTSO allows you to number arbitrarily, but kind of touchy with diagnoses, could confuse the issue. BUT I don't think it'd be wrong to number as follows:

1. INTERNAL DERANGEMENT, RIGHT KNEE.
2. TEAR OF LATERAL MENISCUS, RULE OUT MEDIAL MENISCUS TEAR.
3. EARLY DEGENERATIVE ARTHRITIS.

OR if you don't number, I'd punctuate:
INTERNAL DERANGEMENT, RIGHT KNEE. TEAR OF THE LATERAL MENISCUS. RULE OUT MEDIAL MENISCUS TEAR. EARLY DEGENERATIVE ARTHRITIS.

or you could put semi-colons in between.

But I'd put "DIAGNOSES." These are clearly more than one issue.
depends, does he say a few or 3?...sm
Subject: depends, does he say a few or 3?...sm

if he says a few then spell it all out, a few millimeters by a few millimeters as it is not a specific measure.  Also may need to drop the .0 on 3.0, most of the time trailing zero is dropped unless verbatim.   
depends on how it is being used
Subject: depends on how it is being used


depends
Subject: depends

It depends on what the client wants
It depends...
Subject: It depends...

If it's part of the name of the clinic (i.e., "Smith Family Planning Clinic"), yes.


If not, (i.e., "The patient went to the family planning clinic."), no.


depends
Subject: depends

They are hyphenated when as a group they form an adjective, a compound modifier. So it's an "over-the-counter medication" -- but the medication was purchased over the counter.

The medication is taken as needed, but it is taken on an as-needed basis.

Think of it this way: if you can substitute the phrase with "blue" and it makes sense, it gets hyphenated.
Depends on the doc...
Subject: Depends on the doc...

Patella tendinitis refers to the patella itself. Patellar tendinitis refers to the general area of the patella. They both actually are the same. Condyle-condylar. Patella-patellar. Interchangeable. I usually use the word that the doc does. There really is no difference except sometimes one sounds better in the context of the sentence. :-)
it depends...is it before or after the noun? sm
Subject: it depends...is it before or after the noun? sm

It could be "a 2-3-mm lesion," or "The lesion was 2-3 mm in size." Generally, cardinal numbers plus unit-of-measurement adjectives are hyphenated before the noun.
it depends on how it is dictated...sm
Subject: it depends on how it is dictated...sm

6600 (no comma) or 6.6 if they say it that way; if they say 6.6 thousand then you give them *6.6 thousand*


 


just trying to be funny here, but depends --sm
Subject: just trying to be funny here, but depends --sm

on WHICH "leg" he was referring to that was "nonpeeing." (sorry. couldn't resist) lol
Depends where you work
Subject: Depends where you work

and if they go by AAMT or not.
It really depends on whether the noun being
Subject: It really depends on whether the noun being

follows:

Austin-Moore-type prosthesis
prosthese is an Austin-Moore type
Depends on who you work for....
Subject: Depends on who you work for....

some don't like you to use hyphens some don't care. I have accounts that are both ways.
Depends on who's doing the feeling
Subject: Depends on who's doing the feeling

Sorry, dirty mind. 
And that depends on what the client wants. sm
Subject: And that depends on what the client wants. sm

I really think these are questions you should ask your employer, assuming this is work related. Style and rules can vary from company to company. Most will provide you with a list of rules or specs and sample reports. If they haven't, you might ask for that. When in doubt, I follow BOS guidelines, though.