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Format/Grammar/Punctuation Help (psychiatric)

Posted By: SG on 2007-08-10
In Reply to:

Subject: Format/Grammar/Punctuation Help (psychiatric)

DIAGNOSTIC ASSESSMENT:
AXIS I: Psychosis NOS, schizoaffective disorder, bipolar type versus bipolar I disorder versus a drug induced psychosis, also polysubstance abuse.     Should the word versus be transcribed as a slash or another format in this example?  Thanks!




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Format & Capitalization (psychiatric)
Subject: Format & Capitalization (psychiatric)

Capitalize verbal, performance, and full-scale?  Should I leave the subtest scores in a vertical list arrangement or use a different format?


On this administration of the Wechsler Adult Intelligence Scale-III, Mr. ___ obtained a verbal IQ of 57 (range 53-63), a performance IQ of 64 (range 59-73), and a full-scale IQ of 56 (range 53-61). These scores fall within the mild range of mental deficiency.


The following scatter of subtest scores was obtained:
VERBAL:
Vocabulary: 2
Similarity: 3
Arithmetic: 2
Digit Span: 3
Information: 3
Comprehension: 2


PERFORMANCE:
Picture Completion: 4
Digit Symbol: 4
Block Design: 4
Matrix Reasoning: 5
Picture Arrangement: 4


All the scores above fall within the mentally deficient range and are relatively even.


grammar/punctuation help

"At that juncture she would despite her young age be a candidate for supportive care only."


How should this be punctuated? Help. 


grammar/punctuation help
Subject: grammar/punctuation help

Doc dictates- Total time with the patient was 60 minutes and of that, 40 minutes was dedicated to the direct discussion and consultation of the logistics, risks and benefits, and rationale for radiation therapy.


 


Was or were 40 minutes?  Should it be punctuated with a semicolon?


Total time with the patient was 60 minutes; of that, 40 minutes were dedicated.....


 


thanks


 


Psychiatric pt was in s/l "Enbalston" Acute Inpatitent Psychiatric Unit. sm
Subject: Psychiatric pt was in s/l "Enbalston" Acute Inpatitent Psychiatric Unit. sm

I can't seem to locate this facility.  The pt is from Californiai and has been in Riverview Psychiatric Unit, St. Francis Psychiatric Unit, and Loma Linda Medical Center. 


Just can't find the "Enbalsta, Enbalston, anbolston, inbalston" place. 


Any help? 


Psychiatric help, please!!
Subject: Psychiatric help, please!!

Objective: Thought process within normal limits.  No s/l SIH or psychosis. 


Does anyone know of this (or a close) psychiatric abbreviation?


Thanks.


Psychiatric
Subject: Psychiatric

Am filling in for psych account. Anybody have any good reference sites for this?  TIA
Psychiatric drug help please....
Subject: Psychiatric drug help please....

I am working on a psychiatric progress note and he says ... "Our plan at this time is to increase the ~foquan or zoquan~ to 20 milligrams a day"  This doesn't sound familiar to me and didn't know if it may be new or if someone can offer any help.  Thanks in advance.


Tami


 


RE: Psychiatric drug help please
Subject: RE: Psychiatric drug help please

I am probably not correct, but I thought about Etrafon -
A shot in the dark (?)

ETRAFONŽ Preparations
Schering
Amitriptyline HCl - Perphenazine
Antidepressant - Antipsychotic

Indications And Clinical Uses: The treatment of patients with anxious or agitated depression. Particularly indicated in patients with depression associated with marked psychomotor unrest and anxiety. Etrafon has also been used in some schizophrenic patients who have associated symptoms of depression and in depressed patients suffering from marked agitation, anxiety and tension, which may respond to a phenothiazine agent.


is this a psychiatric report? If so, probably
Subject: is this a psychiatric report? If so, probably


Psychiatric reports.
Subject: Psychiatric reports.

I have a question in regards to psychiatric evaluations.  Would diagnosis or diagnoses be used when typing out Axis I, Axis II, Axis III, etc.? 
Maybe Google psychiatric
Subject: Maybe Google psychiatric

facilities in Michigan?
Psychiatric dictation help please
Subject: Psychiatric dictation help please

Dictator states very clearly "The patient is allergic to erythromycin and tetracillin." What is that???... mixture of tetracycline and a cillin drug??? This is a new one on me HELP!
format
Subject: format

No.1 PDS or #1 PDS? Which is correct?
Format ?
Subject: Format ?

5/5 strength throughout sensation is intact.  So the 5/5 is not at the start of the sentence, how would you reword this phrase?


OB format for G 3, P 1-1-0-2
Subject: OB format for G 3, P 1-1-0-2

Is this how you type that?  I havn't heard it transcribed that way before... Thanks!
Format Help
Subject: Format Help

How do you type the name of a book? Italics or quotations? TIA
Format help
Subject: Format help

I have a dictator who constantly repeats words, phrases, entire sentences!  Do you transcribe it twice or if she has already stated it, leave it out? 
Format ?
Subject: Format ?

Would it be MEDICATIONS: Include


1.


2.


3.


 


H & P Format
Subject: H & P Format

Just when I think I have it on format - I don't.  The following is under PHYSICAL EXAMINATION.  What would the subheading be?



Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on a tandem walk she really has difficulty with that. She does not line up her toes easily, loses her balance very easily with that.   This is typed as dr. dictated. Suggestions would be appreciated. 


S/L psychiatric CONVICTION services.
Subject: S/L psychiatric CONVICTION services.

The dictator is saying "He will continue with psychiatric s/l "conviction" services.  That doesn't make sense to me - or am I missing something??  I can't find anything else that would fit either.  HELP!! and THANKS!! 
psychiatric counseling services? sm
Subject: psychiatric counseling services? sm

Individual, Group and Psychiatric Counseling Services




The Counseling Center is a short-term, focused treatment agency offering individual counseling, group counseling and psychiatric services.
www.bsu.edu/students/cpsc/services/ - 23k - Cached - Similar pages

Psychological and psychiatric counseling services for Clergy ...




Psychological and psychiatric counseling services for Clergy, Priests and Religious professionals.
www.slbmi.com/psychology_religion/index.htm - 27k - Cached - Similar pages

[10 years of social psychiatric counseling services in Hannover]




[10 years of social psychiatric counseling services in Hannover] [Article in German] Gephart W.MeSH Terms Community Psychiatry* Counseling* Germany, West ...
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psychiatric outpatient services, maybe? nm
Subject: psychiatric outpatient services, maybe? nm

x
Psychiatric - Hindru Intox
Subject: Psychiatric - Hindru Intox

Context: He was found to be in rhabdomyolysis and hindru intox was positive for amphetamines, benzos, opiates, and THC.  Thanks!!!!!
s/l blunted acid (psychiatric)
Subject: s/l blunted acid (psychiatric)

MENTAL STATUS EXAM:  This is a 39-year-old white male who is alert; oriented to person, place, and partially to date; cooperative; somewhat restless; with blunted s/l acid; normal speech; thought precesses goal-directed; thought contents significant for paranoid delusions of visual hallucinations; insight and judgement poor; cognition not assessed.  Could this be blunted affect or something else?  Thanks!
psychiatric terminology question
Subject: psychiatric terminology question

Dictated as, "Her thought process was linear, logical, and goal directed," or should it be "Her thought process was linear logical and goal directed"?  Since I am unsure, I googled the key words and hit a dead end; that is, never figured out if it is "linear logical" or "linear, logical." 


TIA for advice!!!


I need some assistance on a psychiatric term please. sm
Subject: I need some assistance on a psychiatric term please. sm

It is listed in the Assessment portion of the dictation, and the preceeding text gives no indication as to what this could be.  Any and all help is greatly appreciated.


s/l "Fixed allusion (or illusion) s/l naparecytosis. 


TIA.


Psychiatric - s/l Wahdahlian responses (nm) TIA
Subject: Psychiatric - s/l Wahdahlian responses (nm) TIA

x
Do you mean anhedonia? Is it a psychiatric report?
Subject: Do you mean anhedonia? Is it a psychiatric report?


psychiatric test s/l YBOX
Subject: psychiatric test s/l YBOX

for patient with OCD in anxiety disorders clinic
QUID score psychiatric? nm
Subject: QUID score psychiatric? nm


Abbreviation Format

Hi... Can someone tell me the correct format for what comes after this med in a dictation:  "Zarontin 250 mg 500 500 250 500?"  Is this 500 am, 500 mid-am, 250 afternoon, 500 bedtime?


Thanks! 


Abbreviation Format
Subject: Abbreviation Format

Thanks!  I thought that would be a mega-dose as well, but that's what she said.  I did "slash" them though. 
format question
Subject: format question

Do you put immunizations under the Social History section in a report or by themselves?  I'm not testing, just confused.  The doctor is dictating:  "All immunizations are up to date" under Social  History.  Thanks.
Format question...
Subject: Format question...

Hi, I'm wondering whether AAMT BOS says to type this:  "image #31 series 3" or this: "image #31, series 3."  Comma or no?


Thank you!  :D


Format question
Subject: Format question

This is so small I hate to ask, but everytime I type this it just looks odd no matter what way I type it and would like to know how another MT would type this. 


If someone has a dull aching sensation or sharp stabbing sensation would you hiphenate (dull-aching sensation) or slash (dull/aching sensation) or just leave it (dull aching sensation)?  Thanks for any input to my "stupid" question.  


I would say cecal and S1-S2 is how I format it...nm
Subject: I would say cecal and S1-S2 is how I format it...nm

s
number format
Subject: number format

When transcribing a very large number, "1 million 120 thousand" is it considered more acceptable to use words or just to stick to numbers? 
Format question
Subject: Format question

I was hoping someone might be able to give me the rule for this.....Should departments be capitalized?  For instance, "she saw University of Virginia orthopedics"  Should orthopedics be capitalized or not? I'm always confused about this:)


format question
Subject: format question

I was taught that if the "orthopedics" came after the name of the place, it should be capitalized (UoV Orthopedics). If not, it wouldn't be capitalized(orthopedic department at UoV). Please correct me if I'm wrong, anyone! :)
Punct? format?
Subject: Punct? format?


REVIEW OF SYSTEMS


He is 6 feet tall and weighs 260 pounds. His weight has been stable. No rashes. No problems with his eyes, ears, nose or mouth. Respiratory: he is positive for a smoker, half pack per day, with a smokers cough. Cardiovascular: has a history of hypertension. No GI/GU problems. Musculoskeletal is stated in the HPI. No neurological or hematological disorders.


Is this how this should be put in paragraph form with the Respiratory and Cardiovascular??


Radiology Format ??
Subject: Radiology Format ??


DUPLEX SCAN OF LEGS



Duplex scan of the arterioles system in the legs was performed and results are as follows:



RIGHT LEG: On the right side,


Is this layout correct? or is it


RIGHT LEG no colon? then drop down a line? Thanks


Format rules in MT

Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home.   Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way.   Problem #1 - HYPERTENSION.  The patient is taking lisinopril currently.....  or if the doc did not say PROBLEM #1, then you transcribed it 1.  HYPERTENSION.  Blah, blah, blah.   When did this change and become wrong?  Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem.  Is this in the so-called AHDI BOS2? 


IMHO, using the capitalization on the problem is much easier to read, than this...


1.  Hypertension.  The blah, blah, blah..


2.  Diabetes mellitus type 2.  Uncontrolled.  Not compliant.


Any QAers out there can answer this one for this old school nitpicker?


? psychiatric addiction services -- just a guess. (nm)
Subject: ? psychiatric addiction services -- just a guess. (nm)

x
_____ status? (Psychiatric word help)
Subject: _____ status? (Psychiatric word help)

Mr... appears for this appointment neatly and appropriately dressed and groomed.  He is cooperative.  His speech is fully understandable to the examiner.  He smiles much of the time; he is cooperative.  ______ status revealed that he knew that George Bush was the current president and that Bill Clinton preceded him.  He denies hearing any voices.  He denies any other significant psychiatric problems.  He did not show any unusual or bizarre behaviors or manorisms.  He is not currently on any medication.


(Sorry, I posted this yesterday but am still unclear and think I may have been misleading in my wording)


Thanks!


abbrev. acronym help - 2 questions - psychiatric
Subject: abbrev. acronym help - 2 questions - psychiatric

I cannot restart a Depakote due to increased LSTs.  I will recheck ACPK in a.m. -- Is this LST or LSP or other?  ACPK or ACBK or other?  Thanks!!!


psychiatric patient receiving s/l HCT as outpatient.
Subject: psychiatric patient receiving s/l HCT as outpatient.


FDA: Chantix May Pose Psychiatric Risks
Subject: FDA: Chantix May Pose Psychiatric Risks


Pt on s/l "lovera dash 20 a one". Psychiatric pt with asthma. nm
Subject: Pt on s/l "lovera dash 20 a one". Psychiatric pt with asthma. nm


format that to your accts specs (sm)
Subject: format that to your accts specs (sm)

a.m., AM, whatever your acct likes! LOL
Format for multiple problems
Subject: Format for multiple problems

Can someone show me an example of how to type a report that has multiple problems. The doctor does one problem completely, then goes onto the next one.

It doesn't look right typing HISTORY OF PRESENT ILLNESS, PHYSICAL EXAMINATION twice throughout the report.

Thanks
Go to format/paragraph and you'll see it. nm
Subject: Go to format/paragraph and you'll see it. nm