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I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.

Posted By: MT50 on 2008-02-22
In Reply to: herold versus herald (as in illness) - sgb

Subject: I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.




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herold versus herald (as in illness)
Subject: herold versus herald (as in illness)

This doctor habitually spells herald/herold, i.e., as in herald symptoms.. Is is herald or herold? Thanks.
herald spots
Subject: herald spots


there is a herald plaque...nm
Subject: there is a herald plaque...nm

xx
Skin exam - s/l herald/harold patch nm
Subject: Skin exam - s/l herald/harold patch nm


Speaking of QA, here's one for ya'...sm
Subject: Speaking of QA, here's one for ya'...sm

Last line of the report, dictating physician says "I will page Dr. so-and-so and discuss with him."  The title "Dr." was inadvertantly left out (mybad), admittedly an error from typing too fast and didn't catch it.  QA pulled this report and marked it as a "critical error affecting document integrity."  I appealed the ruling arguing that it should be considered merely as a typo as document integrity as it pertains to accurate documentation of patient health care (which is what these documents are for) and proper transcription style had not been affected in any way.  QA board upheld the ruling implying in their reasoning that the doctor could be offended, i.e., his ego could be bruised, by failing to transcribe the title he worked so hard to achieve. 


Your thoughts - typo or critical error affecting document integrity?


Speaking of numbers...
Subject: Speaking of numbers...

What are the rules according to AAMT BOS on spelling out numbers in reports. If doc says...Patient has had headaches for the past two days...do I spell out two or do I put a number 2?

Thanks for your help.
Generally speaking (sm)
Subject: Generally speaking (sm)

affect is a verb and effect is a noun. There are only 2 exceptions - when affect is used in psych reports referring to their general attitude and when effect is used as a verb meaning "to bring about" as in "to effect a change in someone". Try to keep it simple.
speaking of misspelled, LOL nm
Subject: speaking of misspelled, LOL nm

nm
Speaking of presumptive
Subject: Speaking of presumptive

You made an assumption that I made my comment based on my "moral compass."  You are the one being presumptive.  As it so happens, I became an MT because the job I used to have did not allow me to go back to school.  I recently got my second bachelor's in psychology, graduating summa cum laude I might add, and have been accepted to grad school for school psychology at one of the most competitive schools in the state.  So I beg your pardon but the information I gave is not my moral compass.  It comes from the extensive education I have received.  In addition, I have experience working with kids with developmental delays and my best friend growing up had autism.  I assure you if a doctor used that word with some of my friends who have children with disabilities, not only would the doctor get an earful so would the AMA.


Thanks. That has to be it. He has a little speaking dyslexia going on. (nm)
Subject: Thanks. That has to be it. He has a little speaking dyslexia going on. (nm)


Visually speaking, I like q.8h.
Subject: Visually speaking, I like q.8h.


Is he spanish speaking?
Subject: Is he spanish speaking?

the word sin in Spanish means without.


If she is speaking REALLY fast...
Subject: If she is speaking REALLY fast...

she may be saying parenteral nutrition.
Is he speaking really fast??
Subject: Is he speaking really fast??

Follicular maybe
Maybe, if speaking really fast...
Subject: Maybe, if speaking really fast...

doc is saying pressure recording device. I had a hard time once figuring out that piddy-did was simply the punctuation at the end of every sentence. :-)
podiatrist speaking PARIOSALIVATOR?
Subject: podiatrist speaking PARIOSALIVATOR?

borders of the right great toenail were freed from their underlying attachments to the nailbed with a  S/L PARIOSALIVATOR.. 


Any help - please? 


Dr speaking fast...am I hearing this right?
Subject: Dr speaking fast...am I hearing this right?

(In review of systems)


NECK: Supple without mass.  ABDOMEN: Soft.  He does have some epigastric discomfort.  No hepatasplenomegaly, S/L mass appreicated, no guarding rebound.


am I hearing this right....if not any ideas?


volar? positionally speaking of course.
Subject: volar? positionally speaking of course.


doubt
Subject: doubt

_____ (Evos) of a 40-year-old female who comes in to the office for follow up on chronic.....
You are without a doubt - sm
Subject: You are without a doubt - sm

a very unhappy person.  I feel very sorry for you. 


Any doubt
Subject: Any doubt

on vitals or med doses...ALWAYS A BLANK. :-)
total guess: trouble speaking? nm
Subject: total guess: trouble speaking? nm


Speaking of Whitney, despite it all, I hope she makes the
Subject: Speaking of Whitney, despite it all, I hope she makes the

biggest come back ever.  Her voice is phenomenal.  She is one of the very few people (less than 3% in the U.S. and Europe) who have perfected pitch.
Speaking of ears clogged with cerumen, are there
Subject: Speaking of ears clogged with cerumen, are there

any ENT MTs who know if there is another product, other than Debrox, or Cerumenix (which was by RX only, but discontinued) to remove chronic earwax, other than going to the ENT to have them irrigated and removed with a curette?


I can't seem to find any drug on the market; prescription or otherwise, other than those mentioned above, which were of no benefit.


Your help is greatly appreciated.  Thanks.


equivocal - no doubt about it.....*LOL*
Subject: equivocal - no doubt about it.....*LOL*


Well, I doubt that would help her diet!!
Subject: Well, I doubt that would help her diet!!


I would - but I doubt they'd listen
Subject: I would - but I doubt they'd listen

If you're QA, though, I can nominate you for QA of the month!  You deserve it.
Strongly doubt it
Subject: Strongly doubt it

nm
grammar doubt
Subject: grammar doubt

today for routine (follow up or followup) of hypertension.
grammar doubt
Subject: grammar doubt

follow up
doubt with radiology again
Subject: doubt with radiology again

Bony _____ (s* ---- tion) projects the distal right of the radial styloid process, which does not appear to be posttraumatic.
CT Brain doubt
Subject: CT Brain doubt

A 5-mm-thick _____ obtained through the brain with intravenous administration of contrast.
THANKS-don't you hate it when you doubt yourself?
Subject: THANKS-don't you hate it when you doubt yourself?


I thought of that, but the doctor is pretty plain speaking
Subject: I thought of that, but the doctor is pretty plain speaking

thanks for your thoughts.. It indeed might be what he means but doesn't say right.. you know how that goes
In PE of the Ears saying TMs are s/l purligurd?
Subject: In PE of the Ears saying TMs are s/l purligurd?

In degrees of ROM or in end range or ROM? I doubt sm
Subject: In degrees of ROM or in end range or ROM? I doubt sm

it is Dupuytren etc.  nm


Thanks for replying. You confirmed it for me so no doubt now.
Subject: Thanks for replying. You confirmed it for me so no doubt now.


Ct abdomen and pelvis doubt
Subject: Ct abdomen and pelvis doubt

multiloculated or ____ (simi subtrated) cyst in the pancreatic map.
Doubt with cervical myelogram
Subject: Doubt with cervical myelogram

Dictating in 2 position:


1.  _____(codstone) bone graft is in excellent position.


2.  HIs ____(po*city) of bone formation along the edges of _____(c*stone) graft, which is unexpected in more cortical nature.


 


No, I doubt it since grip strength was 35/50..
Subject: No, I doubt it since grip strength was 35/50..

something else starting with a T that is only 11-12 pounds.
Thanks everyone. This guy is a real trip. Never heard such horrible speaking skills!
Subject: Thanks everyone. This guy is a real trip. Never heard such horrible speaking skills!


If I'm not 'speaking' clearly it is because I've had to listen to this mush mouth, speed talker for the past 8 hours and am only about 3/4 done with my quota.  I've never had so much trouble... even my ESL doctor makes better sense than this guy.


Using a question mark to indicate doubt or uncertainty sm
BOS says:
Use an ending question mark to indicate doubt or uncertainty.

Sometimes, particularly with diagnoses, a question mark is placed before a
statement in order to indicate uncertainty.

Placement either before or after the questionable material is acceptable, but
do not place the question mark both before and after.

Ex:

His cholesterol levels were high normal (or minimally elevated?).

D: Diagnosis: Angina question mark
T: Diagnosis: Angina?
or Diagnosis: ?Angina.
not Diagnosis: ?Angina?

Note: There is no space after the question mark in ?Angina.

=)

Rennie
www.renesue.com
I doubt highly that a stricture or lesion would
Subject: I doubt highly that a stricture or lesion would

improve a patient's nutritional status., but rather do the complete opposite. I think the physician meant to dictate "GI" physician since he/she mentioned the dysphagia in the dictation, which is also a common place for strictures or lesions to develop.
Client preferences rule here. If in doubt, sm
Subject: Client preferences rule here. If in doubt, sm

here's what I've always done:

He was given a do-not-resuscitate order.

I think my high school English teacher would prefer it thusly;)

He was given a "do-not-resuscitate" order.

Like Txczech said, sometimes these are bolded and capitalized to alert treating physicians of patients' wishes, similar to allergy statements. Client preference, again.

Unless you know for sure that the client does not have a special order called the Do-Not-Resuscitate Order, lowercase it. (I think this is what you might have been considering.)

Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again
Subject: Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again. nm

c
Meds and dosages scare me, so when in doubt...
Subject: Meds and dosages scare me, so when in doubt...

I always blank/flag it. 
Doubt you give 15 refills for narcotics.
Subject: Doubt you give 15 refills for narcotics.

x
speaking of recurrent thyroid cancer..so in that area the intra-media-sty-num sm
Subject: speaking of recurrent thyroid cancer..so in that area the intra-media-sty-num sm

Interestingly the PET scan revealed minimal FDG uptake in the right thyroid bed consistent with the right anterior tracheal lesion, and also minimal uptake in what is believed to be persistent thymic tissue in the "intra-media-stynum", but nowhere else is it noted.  MRI was reviewed as well.  This confirms a 1.4 cm enlarged lymph node on the right side at the level of C3......


Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
Subject: Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis


Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something lik
Subject: Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something like coronary obstruction artery "something" syndrome...? Just can't get it :( THanx though!


It's too late to tell you to leave a blank. Doubt "os finder." nm
x