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Good post for newbies and a review for us oldies who have sm

Posted By: nm on 2006-04-24
In Reply to: Could be - SoCal

Subject: Good post for newbies and a review for us oldies who have sm

been transcribing these studies since they were first initiated years ago.


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It is Review of Systems and not Review of Symptoms.
Subject: It is Review of Systems and not Review of Symptoms.


Good PI for (post-injection)? nm
Subject: Good PI for (post-injection)? nm


Probably would get more insight if you post this under MEDQUIST. Good luck to you!
Subject: Probably would get more insight if you post this under MEDQUIST. Good luck to you!


Good save, Spice! Not my post, but I like being able to learn something new everyday. Thx! :) nm
Subject: Good save, Spice! Not my post, but I like being able to learn something new everyday. Thx! :) nm

s
To my newbies out there in MT land: sm
Subject: To my newbies out there in MT land: sm

I've tutored many MTs over the years, and have always added little anecdotes to their "lessons" (whether they liked it or not) which seemed to help them remember certain things.  I was taught that way, and it seemed to work. 


Anyway, what you newbies really, really need to do is brush up on your English, spelling, punctuation and grammar skills.  If you make a mistake with a medical term, more than likely your QA will forgive that.  But if you make errors on things you should have learned in high school, it's bad.  There is no excuse in MT to make these kinds of mistakes. 


My anecdote now:  When I was in college, because of taking extra courses not required in my curriculum, I had to take courses which were not typical of my curriculum but were acceptable for the credits I needed.  One was called "Advanced rhetoric and expositional writing."  There were no other med sec majors in my class.  These were people who were majoring in politics, government, physics, economics, and other lofty 4+years things.  They were able to spin about what was going on with the Vietnam war, the race riots, etc. It was a hot time (in a bad way) and the issues were mindblowing.  The president of SDS (Students for a Democratic Society) was in my class!!!   I was in awe.  I didn't fit.  Little med secretarial major me was so naive that I wrote on subjects like "my most embarrassing moments," etc.  My subject matter just couldn't compare with these other classmates who were so far ahead of me, but I got a B+ (!!!)  for the course because of my grammar, spelling, and punctuation skills. 


Lesson:  Goes to show ya how important this is.  Good English skills is a foundation everyone needs--especially in this business. 


 


I find the old-timers use "c" and newbies use "k".
Subject: I find the old-timers use "c" and newbies use "k".


I agree that we need more context. However, newbies don't realize this and deserve our patience.
x
Lots of newbies here not aware of these subtle spelling/area
Subject: Lots of newbies here not aware of these subtle spelling/area

s
On a similar note, I copied and pasted a URL/Link & sent with my post, but it was absent from post.
Subject: On a similar note, I copied and pasted a URL/Link & sent with my post, but it was absent from post.

x
ADMIN, can you post a perm msg to post LOTS of context when asking about WORDS?
Subject: ADMIN, can you post a perm msg to post LOTS of context when asking about WORDS?

thanks
X-Ray Review help
Subject: X-Ray Review help

X-RAYS:  Review of her x-rays today show that she has a three-part fracture of her proximal humerus with head rotated and the (something ending with) 'osity' displaced. 


 


Thanks


Thats all in Review of systems.
Subject: Thats all in Review of systems.

Thanks though!
Under review of systems...
Subject: Under review of systems...

Sounds like dictator is saying:


Abdomen:  Soft. Flat. Obese.  Pressure: Soft. Obese.  No point of splenomegaly was noted.


However, it doesn't seem to me that this would fit.  He may be saying another heading instead of pressure but it is too jumbled to tell. 


Also this may be: No signs of [something] or splenomegally is noted.


 


Thanks in advance!


Review of Systems
On Review of Systems, he's saying . . ."@#$#&*&(" : No recent skin rash.  and then something else "@#$#$" : No anemia or lymph gland problems.  Psychiatric - No recent depression.    Can anyone tell me what these headings could possibly be?   I can't even get enough to give you a "sounds like".
In Review of Systems
Subject: In Review of Systems

There is no history of diabetes, polyuria, polydipsia, seizure, stroke, TIA, loss of strength or sensation, or DVT s/l pulmonary mesin around level bleeding. 


It might be 'pulmonary embolism' but I might just be wanting to hear that, it's kind of a stretch.  But the rest...


Any ideas??? Thanks.


Record Review: S/L
Subject: Record Review: S/L

'gluteus piriformis intentious fascia lata' 
Review of systems
Subject: Review of systems

Review of systems include shortness of breath and s/l ricacaria?? Anyone ...help???
Q in Review of Systems
Subject: Q in Review of Systems

When the doc says - Rest of systems: Negative.  do we write it that way or list the systems with Negative next to them all?


Doc doing review. Any ideas? sm
Subject: Doc doing review. Any ideas? sm

Available for review is a s/l “fair-row” seven page typewritten report.
Do you want to know was ROS is? Review of systems.
Subject: Do you want to know was ROS is? Review of systems.


review of systems twice
Subject: review of systems twice

The doc says his normal ROS. At the end of his thought he pauses for a LONG TIME and then says "ROS, on the line, otherwise negative."
So should I do it like I have below or what are your suggestions?

REVIEW OF SYSTEMS: blah blah blah.
A review of systems is otherwise negative.


In review of systems he says,
Subject: In review of systems he says,

"no fevers, chills or sweat s/l size-or-trizer?
Review of Systems
Subject: Review of Systems

Of course...You are correct. I was typing too fast. :-)
Review of Systems
Subject: Review of Systems

I knew that is what you meant.
OP's post inside post says not Harrington rods
Subject: OP's post inside post says not Harrington rods

x
It is indeed "is"....as review is single.
Subject: It is indeed "is"....as review is single.

Boy, if that don't make sense, nuthin' does!  I fried my brain years ago though...a product called White-Out...hey, it was the 80's and what else was there to do in typin' class?
possibly - I am sending for review
Subject: possibly - I am sending for review


Ever heard of this? Xray review
Subject: Ever heard of this? Xray review

Review of his x-rays today show no evidence of any s/l 'ab-lateral compartmental arthritis.


wasn't sure if this was an actual word (short for something) or if he possibly tumbled over his words and just meant to say lateral compartmental . . .


thanks for the help.


Disregard - I marked for QA to review.
Subject: Disregard - I marked for QA to review.


Disregard - I am sending for review
Subject: Disregard - I am sending for review


Not saying ROS of review of systems is negative? nm
Subject: Not saying ROS of review of systems is negative? nm


s/l taw-tur-tile CRP. Lipid lab review.
Subject: s/l taw-tur-tile CRP. Lipid lab review.

 One of those days when I can't understand anyone!


NWMNMT:Good grief, good grief, good grief..If this is the case, the doctor should also explain
Subject: NWMNMT:Good grief, good grief, good grief..If this is the case, the doctor should also explain

the meaning in an ADDENDUM.
How do you know what the doctor meant? GOOD GRIEF, are you the know-it-all (hyphens must be put here, as it is used as a noun!) on this board? Get over yourself!

Who understands what it means without an explanation?
The MOST obvious is apparently like I understood it:
5 packs in 1 year.

Maybe the doctor really meant this, 5 packs per year, so essentially a nonsmoker.

GOOD GRIEF, get over yourself!
Other review of systems showed s/l OS negative
Subject: Other review of systems showed s/l OS negative

Other "review of systems" ____ showed s/l "OS"  negative. 
Review of systems: See HPI (History of Present Illness.)
Subject: Review of systems: See HPI (History of Present Illness.)


review of systems is "pan positive" with a lot of problems. Is this right? nm
Subject: review of systems is "pan positive" with a lot of problems. Is this right? nm


Is this right "A "ten part" review of systems reveal?
Subject: Is this right "A "ten part" review of systems reveal?

n/t
"Female: Negative" under a male's Review of Systems?
Subject: "Female: Negative" under a male's Review of Systems?

This is the only doc i have ever seen do this... can someone explain?  I'm confused.
Psychiatry. Pt with depression and positive s/l "Siggy Capps" review. nm TIA.
Subject: Psychiatry. Pt with depression and positive s/l "Siggy Capps" review. nm TIA.

nm
Review of systems: Chills, night sweats,*commerfid*
Subject: Review of systems: Chills, night sweats,*commerfid*

TIA!
Thanks everyone. I ended up going with edematous paretic, but flagged for review just in case...
Subject: Thanks everyone. I ended up going with edematous paretic, but flagged for review just in case...

nm
14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?
Subject: 14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?

n/t
Pt with migraines with aura, in review of systems, episodic visual s/l C D O's. nm
Subject: Pt with migraines with aura, in review of systems, episodic visual s/l C D O's. nm


Wait...! apparently my post did not post
Subject: Wait...! apparently my post did not post

I would do 60%. I have several doctors that will say 60 (as in ) 6-0. Clarifying the numbers so you don't put 16. They do 50, 5-0 so you don't put 15 because they sound close. It just sounds like sixty-six-zero. Put what you feel is right but I would be from experienc it is 60%
Glad to help. You give good me a good S/L and info. nm
Subject: Glad to help. You give good me a good S/L and info. nm


Glad to help. You give good such good S/L and info. nm
Subject: Glad to help. You give good such good S/L and info. nm


doc reviewing a record. Any ideas? Available for review is a s/l “fair-row” seven page typewritten

Review of MRI shows some mild edema within the pubic s/l syn-th-o-ceel region.
Subject: Review of MRI shows some mild edema within the pubic s/l syn-th-o-ceel region.

Thanks so much!!!
Review of x-rays show a s/l web-a-ray nondisplaced fracture of the lateral malleolus.
Subject: Review of x-rays show a s/l web-a-ray nondisplaced fracture of the lateral malleolus.

TIA :-)
?break in dictation for MT instruction? i see "add this to review of systems above the extremity
Subject: ?break in dictation for MT instruction? i see "add this to review of systems above the extremity section" in your s/l ?? nm ??


In Review of systems: Hem/Lymph: Has long-term bruising, no s/l atreemia, noncontributory. nm
Subject: In Review of systems: Hem/Lymph: Has long-term bruising, no s/l atreemia, noncontributory. nm