Home     Contact Us    
Main Board Job Seeker's Board Job Wanted Board Resume Bank Company Board Word Help Medquist New MTs Classifieds Offshore Concerns VR/Speech Recognition Tech Help Coding/Medical Billing
Gab Board Politics Comedy Stop Health Issues
ADVERTISEMENT




Serving Over 20,000 US Medical Transcriptionists

Format for multiple problems

Posted By: tf on 2006-06-30
In Reply to:

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


Complete Discussion Below: marks the location of current message within thread

The messages you are viewing are archived/old.
To view latest messages and participate in discussions, select the boards given in left menu


Other related messages found in our database

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. 


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?


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

a.m., AM, whatever your acct likes! LOL
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.


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


In MSWord, go to Format, Font,..
Subject: In MSWord, go to Format, Font,..

Effects, place a check mark next to Subscript.
Just a general question on format
Subject: Just a general question on format

I have been using these forums for a while now and I keep seeing people using "nm" and "sm". What does this mean?

nm = no message
sm = see message

Just a guess


Time format in BOS 3rd edition
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever.

I do intend to buy my own soon but I have to wait till payday. :(


Much appreciated !
Format/Grammar/Punctuation Help (psychiatric)
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!


Medquist letter format question...
Subject: Medquist letter format question...

I never usually have to type letters so I am unsure of the format.  Are we supposed to type the "Sincerely," and are we supposed to indent it? 


Thanks!


He dictates in SOAP format so that might look out of place.
Subject: He dictates in SOAP format so that might look out of place.


Time format rules in BOS 3rd edition?
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever is easier.

I do intend to buy my own soon but I have to wait till payday and I'm starting a new company right now that uses that book :(

TIA !
Axis format but employer prevails
Subject: Axis format but employer prevails

I go like so


Axis   I


          xxxxx


          xxxxx


          xxxxx


Axis   II


 


Axis  III


 


Axis   IV


 


Axis   V



 


 


 


3 months' time is the correct format
Subject: 3 months' time is the correct format


SOAP is a really archiac format, rarely used today
Subject: SOAP is a really archiac format, rarely used today

and occasionally used today but rare.....


As q. day is a dangerous abbreviation, the correct format is p.o. daily...:)...nm
Subject: As q. day is a dangerous abbreviation, the correct format is p.o. daily...:)...nm

x
multiple?
Subject: multiple?


multiple criteria for LVH?
Subject: multiple criteria for LVH?


Pt with multiple sclerosis. sm
Subject: Pt with multiple sclerosis. sm

Motor strength - right over left - Deltoid 5/4, biceps 5/4, triceps 5/4, grip 5/4, s/l "AOSL" 5/4
multiple vitamin D?
Subject: multiple vitamin D?

Is there such a thing as a multiple vitamin D?  I'm not sure if he is saying just multiple vitamin, which would make sense...but then it sounds like he sticks in the word "D"  Has anyone ever had that dictated?


Thanks.....


in regards to multiple sclerosis
Subject: in regards to multiple sclerosis

s
Rhymes with multiple
Subject: Rhymes with multiple

No, it rhymes with multiple. But thanks for the suggestion.
multiple cystomatrophy?
Subject: multiple cystomatrophy?

This is in regards to a neurologic assessment and sounds like multiple cystomatrophy.  Any ideas? 
Pt with multiple myeloma - sm
Subject: Pt with multiple myeloma - sm

Will have chemo and then will be on prednisone and prochlorperazine as well as s/l alkana.

Thanks for helping!
for multiple myeloma
Subject: for multiple myeloma

sounds like "melfim", any clues?  Tx!
maybe multiple "bone" ...??
Subject: maybe multiple "bone" ...??


Multiple "flexions or reflections" of
Subject: Multiple "flexions or reflections" of

intraluminal air within the gastrointestinal tract that has the appearance of an ileus.


Flexions???? Anyone?


 


Thanx


multiple groups of blisters? nm
Subject: multiple groups of blisters? nm


Has the patient had multiple falls? nm
Subject: Has the patient had multiple falls? nm

x
Maybe there were multiple tests done, and one was over a million.
Subject: Maybe there were multiple tests done, and one was over a million.

Just an idea.
woman having multiple babies s/l
Subject: woman having multiple babies s/l

high prematurity rates and (sounds like "manano" compromise of the fetus. 


 


thank you for your help :)


 


Not a problem, I have them multiple times a day :-)
Subject: Not a problem, I have them multiple times a day :-)


multiple pulmonary opacities....nm
Subject: multiple pulmonary opacities....nm


multiple atypical cocci?
Subject: multiple atypical cocci?