ER admission note help please
Posted By: sassee on 2007-10-08
In Reply to:
Subject: ER admission note help please
The patient had diminished sphincter tone. The patient did receive cow littix prior to the exam.
This patient had been in a car accident, she was intubated, combative, and had 2 broken legs. Any ideas?
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BVP was 8/8...on obstetrics admission...sm
Subject: BVP was 8/8...on obstetrics admission...sm
Is BVP correct, I can't find this abbreviation anywhere??? Thanks!
s/l MOD was called for admission. sm
Subject: s/l MOD was called for admission. sm
the patient was hemodynamically stable, s/l MOD was called for admission secondary to GI bleed. the patient was transferred to the s/l MOD service ???
maybe admission H&P (history and physical). NM
Subject: maybe admission H&P (history and physical). NM
x
its in a list of meds on admission, no dosage
Subject: its in a list of meds on admission, no dosage
pt has diabetes, asthma, migraines, gastroparesis
refer to the admission agency?? for details
Subject: refer to the admission agency?? for details
Do admission orders need to be expanded? eg. C&S, CBC, STAT
Subject: Do admission orders need to be expanded? eg. C&S, CBC, STAT
Thanks for your help.
Outpatient hold admission versus inpatient
Subject: Outpatient hold admission versus inpatient
Please read this with a little grain of salt, since I don't have enough info to be sure in this case, but this has happened to me before. Most hospitals and most insurance companies have a "24 hour hold bed" policy of some sort. The patient is considered an outpatient, (and charged the lesser "hold bed" charge) even though admitted to the hospital, for the first 24 hours, or 23 hours and 59 minutes. Maybe this doc is saying that the EKG was done at that time in the admission - hour #23, minute #____. Again, use caution, and if this is the case, the doctor sure SHOULD have said "at 23 hours X minutes after" admission or clarified it somehow. But this is just food for thought, since I have had docs dictate using the number of hours since the patient was admitted, though I'm happy to say they the docs always made it known that that's the way they were counting down the hold bed time.
just guessing, could it be admission and disch (A&D)so pt can get hospice care afterwards?
Subject: just guessing, could it be admission and disch (A&D)so pt can get hospice care afterwards?
tisbar injection? located in a list of meds on admission
Subject: tisbar injection? located in a list of meds on admission
HOSPITAL COURSE: Fish?? admission history and physical for details
Subject: HOSPITAL COURSE: Fish?? admission history and physical for details
Hi, Amy, PORT score is for pneumonia severity on admission, predicted outcome.....nm
Subject: Hi, Amy, PORT score is for pneumonia severity on admission, predicted outcome.....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
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???
note, no h on the end.
Subject: note, no h on the end.
x
Op note help
Subject: Op note help
ORIF surgery: Intraoperative s/l FLORA showed excellent alignment of the implants.
Note put above
Subject: Note put above
what does it mean when she dictates "note, put above..." before a sentence? i'm confused.
not 100% sure, but I don't think so--also, another note
Subject: not 100% sure, but I don't think so--also, another note
should your first part of your message say "afferent pupillary defect" ?? instead of papillary
See note
Subject: See note
This is what you are looking for.
http://www.fda.gov/cdrh/pdf/p000040.html
Lilly
Thanks for everyone's help. I sent it in with a note for them to let me know. sm
Subject: Thanks for everyone's help. I sent it in with a note for them to let me know. sm
Hopefully, by boss will get back to me, and I will let you all know. Thanks again!
op note
Subject: op note
s/l groshime single lumen catheter
see note
Subject: see note
first word may be lucencies second word might be bezoar
Thank you! Will make a note of it. nm
Subject: Thank you! Will make a note of it. nm
x
Surgical note. sm
Subject: Surgical note. sm
A tornikot was used for hemostasis. He actually spelled it with a "c" rather than "k", but I can find neither.
He said, "not tourniquet, but tornicot".
clinic note help
Subject: clinic note help
Patient is accompanied by her husband today who is very concerned regarding recent symptoms of numbness and tingling in the lateral aspect of the left and right arm. ***This is been ongoing x 2 to 4 weeks.**** . is this the correct way to transcribe this? The last sentence is the questionable.... thanks for all your help!!
clinic note
Subject: clinic note
thanks for your help, I am a new MT and I am a little confused with some things. thanks again!!!
clinic note
Subject: clinic note
the doctor says "this has been ongoing times 2 to 4 weeks" i was not sure how to transcribe that.
clinic note
Subject: clinic note
Your a wonderful help!!!!
progress note
Subject: progress note
On this progress note it sounds like the doctor says "blood pressure 167/82, heart rate is 90, resperate 20, T max is 100.8."
Should that be respirations 20, temperature at max 100.8? thanks
progress note
Subject: progress note
thanks so much for your help you are right!!!
progress note
Subject: progress note
thanks for your help!!!
progress note help please!!!
Subject: progress note help please!!!
Blood pressure 167/82. Heart rate is 90, respiratory rate 20, Temperature at max is 100.8. No JVD lungs and expiratory wheezes. There are some rales in the right base. Heart without ** and edema. **120, **3.4, chloride 94, ** 25, glucose 91, BUN 9, creatinine .6, calcium 8.5, white count is 5.7, hemoglobin 8.9 down from 10 yesterday, platelet count 234,000, 6 lymphs, 10 minus 1 basophiles, 7 bands, 76 segs.~~~~ after heart without--it sounds like a extremity then ssss sound. the other sounds like Sims 120. the other sounds like seven and a 3.4. the other sounds like bacum. ANY HELP WOULD BE GREATLY APPRECIATED!!!!
Progress note help
Subject: Progress note help
Heart: Without? lower extremity edema. Sodium 120, potassium 3.4, chloride 94, bicarb 25.
Also, probably should be temperature T-max is 100.8. No JVD. Lungs: End-expiratory wheezes.
progress note help
Subject: progress note help
You are wonderful. I can't thank you enough!!!!!!!!!!
clinic note help
Subject: clinic note help
does a doctor usually use the word relay example: Patient mainly relays that she has trouble falling asleep at bedtime. 
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