Doc dictates s/l Aluin but spells Alleyn for wound care....
Posted By: Stumped on 2005-10-10
In Reply to:
Subject: Doc dictates s/l Aluin but spells Alleyn for wound care....
with an unna boot...anyone know what this could be? Can't find any wound care info....Alluin is what is sounds like to me...TIA!!!
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Subject: any wound care people out there?
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Subject: What's he getting now that might need to be continued - wound care, IV
s
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Subject: Site for Wound Care?
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Subject: s/l Bos-a-cream for wound care? nm
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Subject: Wound care links for you. sm
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Subject: Allevyn adhesive is used in wound care. nm
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Subject: Under PMH. MD dictates: sm
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Subject: What do you do when the doc dictates sm
... and I gave the patient 50 "mikes" of whatever medication. One said to spell it m-i-q-u-e-s, one said to use m-i-k-e-s, and one hospital said not to use it at all. So, does it stand for micrograms? Should we use slang? Aghh! Help, please.
I would put as doc dictates..sm
Subject: I would put as doc dictates..sm
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Subject: Exactly the way MD dictates it
If the patient could see anything at all (I had one today where the patient could see 20/1760), then the MD would have given the value, but when there is nothing there, you just type nothing. I have a verbatim account, but even if I didn't, I still would not change it to 20/0 as that lone "0" could be mistaken as something else.
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Subject: If a Dr. dictates
"posterior tib", meaning posterior tibial artery, do you type the abbreviation or go ahead and type out tibial?
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Subject: if that's the way he/she dictates it...then yes I would. nm
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What I would do: Since doc spells it, and
Subject: What I would do: Since doc spells it, and
you have exhausted all your references, I'd type it the way he spelled it and then flag it, saying that the doctor spelled it that way. That covers you. Docs are notorious bad spellers, but he might be privy to something so new it's not on the books yet.
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Subject: Probably says YAZ and then spells --Y-A-Z
Similar to Yasmin
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Subject: Don't think that's it, he very clearly spells it.
But thanks anyway, I just left it blank.
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His aortic valve appeared well-(s/l seated). I found some examples like that, but am unsure of certainty and spelling accuracy? Thank you in advance for any help.
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Subject: Think that one is bad? my md dictates things like this...sm
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Subject: I have a doc that dictates same thing
mine means adenosine thallium
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Subject: I leave it as whatever the doc dictates.
It's not my job to keep them politically correct.
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Subject: Do I change it when he dictates cc? nm
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I have a psychiatrist who dictates like that. sm
Subject: I have a psychiatrist who dictates like that. sm
I leave most of his stuff as is even though the account is not verbatim. A lot of times I end up wondering WTH he is talking about. When I first got his dictations I was going back to read and relisten because I thought I must have scrambled something. Give them what they dictate, if they don't like what they read maybe they'll take the time to think before they dictate next time.
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Subject: You transcribe what he/she dictates.
You transcribe the values as dictated. If he says "Cholesterol profile" and then just lists the values, then I would put a colon after profile and just list them.
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Subject: He actucally spells it
but I know that he is spelling it from the way the patient spells it. He often spells medications wrong. I am just going to flag it. Thanks for your help.
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Subject: 99% when a dictator spells anything
whenever they spell anything, I look it up because 99% of the time the dictator has spelled whatever they are trying to spell INCORRECTLY....it's a general rule of thumb for most MTs to do this - look up anything a dictator spells.........because we ALL know this about the dictators after 25+ years..........for some of us....in this biz. 
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Thanks for the help anyway!!
not having any other --HUT-- problems...he spells it
Subject: not having any other --HUT-- problems...he spells it
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