It would be STEMI in hpi and spell it out in diagnoses (unless client profile states otherwise)
Posted By: anon on 2008-08-17
In Reply to: Code - out of here
Subject: It would be STEMI in hpi and spell it out in diagnoses (unless client profile states otherwise)
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- Code STEMI - Linda
- Code - out of here
- It would be STEMI in hpi and spell it out in diagnoses (unless client profile states otherwise) - anon
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I have a client profile that says DO NOT add...
Subject: I have a client profile that says DO NOT add...
paragraphs and I don't add them in those notes. Otherwise, I have never heard of a rule not to. QS may have client profiles confused.
Unless it is in the client profile to do such, I would not (sm)
Subject: Unless it is in the client profile to do such, I would not (sm)
If it states the specific hospital or institution, i.e. General Hospital Diabetes Education Team, then capitalize it. They way you have it would be NOT capitalized. Hope that makes sense (no coffee yet).
if client profile does not specify,
Subject: if client profile does not specify,
either way is acceptable. Personally, I would separate.
depends on client profile...sm
Subject: depends on client profile...sm
Rule of thumb is verbatim........
Depends on client profile...
Subject: Depends on client profile...
If you have a verbatim account I would type as is. If not vertabim I would change it to gastroenterology. Really I think it depends on what your QA would say. Mine would do as above.
check your client profile sm
Subject: check your client profile sm
and follow any instructions you find there, and if it says to follow BOS guidelines, then you should probably type "3."
Don't know if there are other diagnoses involved, but this is what the drug index states it is us
Subject: Don't know if there are other diagnoses involved, but this is what the drug index states it is used for:
to treat chronic hives, premenstrual depression, attention deficit hyperactivity disorder in children, and bedwetting.
25 mg would be the proper dosage also.
according to client profile/wishes. My acounts have it, DNR, etc. all caps (nm)
Subject: according to client profile/wishes. My acounts have it, DNR, etc. all caps (nm)
x
Personally I go by the client profile of the account I am doing. If not specified I put commas.
Subject: Personally I go by the client profile of the account I am doing. If not specified I put commas.
If it was me, I would argue the point with QA on that one.
It would depend on your client profile for that account. I have never run across numbers within the
Subject: It would depend on your client profile for that account. I have never run across numbers within the axes, it would normally just be commas between each diagnosis or periods if that is what the client calls for. Check with that CP if you can.
AAMT BOS2 states that diagnostic abbreviations are acceptable in diagnoses
Subject: AAMT BOS2 states that diagnostic abbreviations are acceptable in diagnoses
The actual Latin conversion for q.h.s. is every hour of sleep, but I go by the client profile for th
Subject: The actual Latin conversion for q.h.s. is every hour of sleep, but I go by the client profile for the facility that I transcribe, some want at bedtime, some do not clarify, some want at hour of sleep.
Can only spell it out if okay with client if
Subject: Can only spell it out if okay with client if
x
By the way, also states in AAMT BOS2 that 0 is correct for sutures as per The United States Pharmaco
Subject: By the way, also states in AAMT BOS2 that 0 is correct for sutures as per The United States Pharmacopeia system sizes...
non-STEMI
Subject: non-STEMI
non-ST elevated myocardial infarction, type as non-STEMI
STEMI
Subject: STEMI
ST segment elevation myocardial infarction.
STEMI
Subject: STEMI
ST segment elevation myocardial infarction.
Code STEMI
Subject: Code STEMI
I got dinged on this on a audit, just wanted to get it right.. would it be Code-STEMI or Code ST-elevation myocardial infarction (STEMI) in an HPI?
L
STEMI , not sure what it stands for though
Subject: STEMI , not sure what it stands for though
s
ST elevation MI... acro..STEMI??? thank you
Subject: ST elevation MI... acro..STEMI??? thank you
non-STEMI..Non-ST Elevated Myocardial Infarction
Subject: non-STEMI..Non-ST Elevated Myocardial Infarction
how about STEMI?? ST elevation myocardial infarction.
Subject: how about STEMI?? ST elevation myocardial infarction.
that might fit in.
non-STEMI (Non-ST Elevated Myocardial Infarction )
Subject: non-STEMI (Non-ST Elevated Myocardial Infarction )
Actually according to Stedmans if dictated -- non-STEMI = non-ST segment myocardial infarction ....
Subject: Actually according to Stedmans if dictated -- non-STEMI = non-ST segment myocardial infarction ....
and if dictated NSTEMI = non-ST segment elevation myocardial infarction.
a heart attack: ST segment elevation myocardial infarction (STEMI):
Subject: a heart attack: ST segment elevation myocardial infarction (STEMI):
DM profile?
Subject: DM profile?
DM profile
Diabetes mellitus profile. this is ordered with labs. Not sure what this consists of. The pt has type-2 diabetes.
? maybe correlation profile ?
Subject: ? maybe correlation profile ?
nm
hypercoagulation profile
Subject: hypercoagulation profile
It's not that this word sounds too crazy, I am just too green to know what it is!
"We will check a hypercoagulable profile, antiphospholipid antibody and *S/L* sector five liden.
Thanks in advance!
BPP (biophysical profile) nm
Subject: BPP (biophysical profile) nm
x
chem profile, perhaps
Subject: chem profile, perhaps
nm
s/l hyperal profile s/m
Subject: s/l hyperal profile s/m
Patient with hyperchloremic metabolic acidosis. Checking sodium, potassium etc.
Also ______lo testing for RTA evaluation. TIA
diurnal profile?
Subject: diurnal profile?
Whole clonine? profile
Subject: Whole clonine? profile
Is there a lab test/profile that is something like clonine? S/L it is pronounced KLAH-NEEN. Any ideas? He doesn't dictate all the specific findings of the test/s, but just mentioned the name so I don't have much to go on.
invalid profile?
Subject: invalid profile?
Can someone tell me why I am getting this "Invalid Profile ID" sticker next to my posts?
I have an ESL who dictates a lipid profile
Subject: I have an ESL who dictates a lipid profile
and then says "lipid profile comment NIHN." What in the world does that mean?
Coalition profile lab test?
Subject: Coalition profile lab test?
s/l coalition profile was negative under lab section in with bilirubin values. Thanks.
fetal biophysical profile? nm
Subject: fetal biophysical profile? nm
s
just a guess... porphyrin profile? nm
Subject: just a guess... porphyrin profile? nm
x
oops - could be profile and/or panel too....
Subject: oops - could be profile and/or panel too....
probably the BMP basic metabolic profile
Subject: probably the BMP basic metabolic profile
Sodium, potassium, etc.
Basic metabolic profile (BMP)
Subject: Basic metabolic profile (BMP)
BMP for basic metabolic profile? nm
Subject: BMP for basic metabolic profile? nm
comprehensive metabolic profile (CMP). ? nm
Subject: comprehensive metabolic profile (CMP). ? nm
Just me, but I do not unless the CP states to do so.
Subject: Just me, but I do not unless the CP states to do so.
yes, BMP, basic metabolic profile, or panel (nm)
Subject: yes, BMP, basic metabolic profile, or panel (nm)
///
Yep, it's a lab profile; I used to type it all the time at my children's
Subject: Yep, it's a lab profile; I used to type it all the time at my children's
nm
bio short for biochemical profile(chem-7 for example)
Subject: bio short for biochemical profile(chem-7 for example)
OR comprehensive basic metabolic profile - nm
Subject: OR comprehensive basic metabolic profile - nm
they also do a high-risk lipid profile for SM
Subject: they also do a high-risk lipid profile for SM
metabolic syndrome ??
QA puts in "EF cardiac profile"
Subject: QA puts in "EF cardiac profile"
but it sure sounds like "ES" Cardiac Profile. I cannot locate it EF or ES when doing research as the way it is dictated. dictator goes on to give lab values such as white count, bun and creatinine and so on. Any suggestions would be very grateful. BTW, even with my new Bose headsets the "ES" is coming in more clearly than it did before!! TIA.
New standard states:
Subject: New standard states:
And I quote: "Numerals, or figures, stand out from the surrounding text and serve a functional purpose in medical reports, where they should be used almost exclusively as opposed to spelled-out numbers.
Exceptions: Judgment and discretion are need when deciding but adjacent numbers require one to be spelled out to avoid confusion.
Use a comma to separate adjacent unrelated numerals if neither can be readily expressed in words and the sentence cannot be readily reworded.
Use numerals for fractions.
Spell out numbers that begin a sentence.
Zero is always spelled out when it stands alone.
Spell out numbers used as pronouns.
That should get you started!
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