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He goes right into the Assessment of elevate PSA and bilat. iguin. hernia

Posted By: kjlange on 2007-10-15
In Reply to: What is the following sentence? - MT50

Subject: He goes right into the Assessment of elevate PSA and bilat. iguin. hernia




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Bilat. lower ext. u/s SM
Subject: Bilat. lower ext. u/s SM

He says:  Ankle-brachial index could be assessed s/l WITH A RIGHT O-SHIMMY. 
the procedure is to elevate the foot passively...nm
Subject: the procedure is to elevate the foot passively...nm

c
Left inguinal hernia repair with Prolene hernia s/l "system large" patch.

Is that right?  Typing on account that I am not usually on and not familair with this doctor?  TIA


 


 


 


 


Incisional hernia hernia repar, s/l Pyriatec mesh? nm
Subject: Incisional hernia hernia repar, s/l Pyriatec mesh? nm

Thanks
Assessment
Subject: Assessment

 


ASSESSMENT: Family history of AAA.  Will proceed with -- s/l "root" ----- to evaluate. 


Anyone have any idea what this is?? I'm drawing a blank.


TY!!


Help with assessment
Subject: Help with assessment

Hypertension with  s/l "realciaporosis"...??


Any ideas??


TIA


assessment ?
Subject: assessment ?

Patient had an s/l EIP - EPL transfer.


in the assessment i would, otherwise no
Subject: in the assessment i would, otherwise no


Assessment ?
Subject: Assessment ?


Assessment ?
Subject: Assessment ?

Can you have an abbreviation like URI in an assessment? Thx. Tina

Assessment
Subject: Assessment

Thank you for the assessment info!!
CAGE assessment?
Subject: CAGE assessment?

CAGE Assessment (Alcohol Abuse)
Powered by:. CAGE Assessment (Alcohol Abuse). For most people who drink, alcohol
is a pleasant addition to eating and to other social activities. ...
https://www.merck.healthinkonline.com/ merckTools/AssessMerckSourceCAGE.asp - 19k - Cached - Similar pages

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Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan

1.      Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago.  I asked him to repeat it, but he forgot.  We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly.  He is not symptomatic.


 


I keep listening over and over to this, and this is all I can make out.  Any clue what he might be referring to??? TIA


It was not a test. It was the assessment.
Subject: It was not a test. It was the assessment.

nm
assessment&plan help!
Subject: assessment&plan help!

If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?


 


ASSESSMENT:



  1. Bilaterally arm numbness.
  2. Nausea.
  3. Health maintenance recommendations.

 


PLAN:



  1. Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion.  She will be referred for MRI with cervical spine.  Patient may need EMG to further access her numbness.
  2. Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn.  She does have chronic nausea and this may be a sign of stomach reflux.  She will be tried on Nexium 40 mg one q.d.  Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night.  We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism.  ___ problem health maintenance and in regards to increase her exercise and changing her diet.  Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram.  When she follows up to see me we will discuss potential options for colon screening.  Patient is to follow-up with me in approximately 1 month time. 

assessment and plan
Subject: assessment and plan

I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not?  TIA!
Should EKG be expanded in Assessment?
Subject: Should EKG be expanded in Assessment?

ASSESSMENT: Abnormal EKG.
question about assessment
Subject: question about assessment

Doc states CABG and mitral valve repair.  He clearly states this together.  Can this be listed as one assessment?  Or should mitral valve repair be next number??


pulmonary assessment
Subject: pulmonary assessment

admitted for elective mediastinoscopy, s/l radio-gram-coscopy?? and left bronchotomy.
Assessment: Vaginitis DX. I never heard of DX?? thanks
Subject: Assessment: Vaginitis DX. I never heard of DX?? thanks


Under assessment: UNCOMPELLING EMG results
Subject: Under assessment: UNCOMPELLING EMG results

Is uncompelling a word?


Or is it noncompelling?


Thanks!


Assessment: Dry skin (s/l ictiosis).
Subject: Assessment: Dry skin (s/l ictiosis).

:-)
Geriatric Assessment Unit
Subject: Geriatric Assessment Unit

.
Oh...assessment is diagnosis..so I would type it out nm
Subject: Oh...assessment is diagnosis..so I would type it out nm

xx
"HO" assessment (alcoholism)
Subject: "HO" assessment (alcoholism)

Has anybody ever heard "EtOH" pronounced as "aitch oh"? Or know what "HO assessment" could mean in relation to alcohol treatment?

"Patient was not eligible for HO assessment."


Thank you!


s/l topo or tolpol for fetal assessment
Subject: s/l topo or tolpol for fetal assessment

 Hi!  Need help as soon as possible.  Typing history and physical for admission of a woman in labor.  Here is what is dicated:


Fetal heart rate tracing is in the 140s and reassuring with good variability, accelerations, and no decelerations.  (s/l topo or tolpol) is minimal if at all.


Thanks in advance!!


It is Mallampati. A classification used in ariway assessment.
Subject: It is Mallampati. A classification used in ariway assessment.

The number would be Class IV
Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
Subject: Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm

nm
Assessment: s/l maseno fracture right ankle. nm
Subject: Assessment: s/l maseno fracture right ankle. nm


CIWA-Clinical Institute Withdrawal Assessment nm
Subject: CIWA-Clinical Institute Withdrawal Assessment nm


Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..

Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time.  They are easy to do though. 
CIWA-Clinical Institute Withdrawal Assessment
Subject: CIWA-Clinical Institute Withdrawal Assessment

score
Think you need CIWA - Clinical Institute Withdrawal Assessment nm
Subject: Think you need CIWA - Clinical Institute Withdrawal Assessment nm

x
clinical institute withdrawal assessment (CIWA) protocol. nm
Subject: clinical institute withdrawal assessment (CIWA) protocol. nm


in assessment says Esoteric ??? failure, blunt chest trauma
Subject: in assessment says Esoteric ??? failure, blunt chest trauma


CIWAClinical Institute Withdrawal Assessment for Alcohol (CIWA) nm
Subject: CIWAClinical Institute Withdrawal Assessment for Alcohol (CIWA) nm


CIWA level - Clinical Institute Withdrawal Assessment
Subject: CIWA level - Clinical Institute Withdrawal Assessment


CIWA score (Clinical Institute Withdrawal Assessment) NM
Subject: CIWA score (Clinical Institute Withdrawal Assessment) NM


Gail Model Risk Assessment Tool (GMRAT) for breast CA. nm
Subject: Gail Model Risk Assessment Tool (GMRAT) for breast CA. nm

information for

Pt had itching she treated with OTC Monistat. Assessment s/l vagini ovitis symptoms.
Subject: Pt had itching she treated with OTC Monistat. Assessment s/l vagini ovitis symptoms.


hernia again
Subject: hernia again

s/l max meshes


 


TIA


hernia?
Subject: hernia?

pt has a paraumbilical ventral hernia.


It is chronically incarcerated most likely with s/l ohmistal of fat. or maybe old mistal


As in incarcerated hernia.
nm
hernia repair
Subject: hernia repair

Dictated "0.25% Marcaine was instilled with a Sawyers throughout the skin and subcutaneous tissues".    Unsure about italicized words.


Thanks for any help.


hernia repair
Subject: hernia repair

This sounded like Sawyers and I could not find a needle name like that. Do you know a website that lists needles, etc?
hernia repair
Subject: hernia repair

This is a hernia repair and it sounds like he is dictating Sawyers. Any ideas?
help please - hernia repair
Subject: help please - hernia repair

the dr. dictates - A small periumbilical incision was made, subcutaneous tissue was bovied through and the s/l "point" or "bone" was dissected down identifying the umbilical stalk. 


TIA!!


hiatal hernia
Subject: hiatal hernia

could it be hiatal hernia repair, or is it crural?
hernia word help?
Subject: hernia word help?


ABDOMEN:  The abdomen is slightly distended with some right upper quadrant pain.  No ** hernias.~~~~the word before hernia S/L amount of hernias or maybe a word that begins with M?  any suggestions?


hernia surgery
Subject: hernia surgery

Doc doing repair of epigastric hernia says he made a small, 3 cm s/l archiform incision.  I can't find anything in my books that come close to matching what I hear.