Personal History is correct
Posted By: NM on 2009-01-07
In Reply to: D: personal history of colon polyps - Julie
Subject: Personal History is correct
nm
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D: personal history of colon polyps
Subject: D: personal history of colon polyps
That's exactly how it was dictated. While all this stuff is "personal," am I missing something here?
Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
Subject: Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
it out. It is a foreigner. He is saying it very fast. History of abnormal petatrie functioning is what is sounds like to me. I have no clue.
history of colorectal history with metastasis to the liver and lymph nodes
Subject: history of colorectal history with metastasis to the liver and lymph nodes
what is your source? personal opinion?
Subject: what is your source? personal opinion?
x
ahh, it is a personal issue - then take it private!
Subject: ahh, it is a personal issue - then take it private!
XX
Client or personal preference
Subject: Client or personal preference
You have several choices here that are correct. You can put E:A reversal, E/A reversal, or E to A reversal. If no client preference, your pick - all are correct.
No, I cannot confirm. I have some personal notes
Subject: No, I cannot confirm. I have some personal notes
that I make and had Segund in them.
Some accounts want no personal info
Subject: Some accounts want no personal info
at all in the report, others want pertinent people listed. It depends on the facility/account.
My personal favorite is "aspirational pneumonia." :)
Subject: My personal favorite is "aspirational pneumonia." :)
x
Personal opinion, I hyphenate it as tib-fib fracture
Subject: Personal opinion, I hyphenate it as tib-fib fracture
Just personal for me, but I have always typed it Sitzmark study
Subject: Just personal for me, but I have always typed it Sitzmark study
Can you please provide the sentence? Or is question of a personal nature?
Subject: Can you please provide the sentence? Or is question of a personal nature?
x
Personal opinion I would hyphate it as supra-SMAS
Subject: Personal opinion I would hyphate it as supra-SMAS
wild guess s/l personal synovarment syndrome
Subject: wild guess s/l personal synovarment syndrome
Right CMC joint arthrosis and s/l personal synovarment syndrome.
Who specifies no personal info? Type what the dictator says. SM
Subject: Who specifies no personal info? Type what the dictator says. SM
The responsibility is in the hands of the dictator. If he or she dictates it, then give it to them... plain and simple.
Personal opinion, but I would only makes this a "header" within a report if the dictator state
Subject: Personal opinion, but I would only makes this a "header" within a report if the dictator states to do so, otherwise I would just type it verbatim in paragraph format.
Personal opinion but I believe it is distal as in determination (i.e. the dorsalis pedis artery puls
Subject: Personal opinion but I believe it is distal as in determination (i.e. the dorsalis pedis artery pulse can be palpated readily lateral to the extensor hallucis longus tendon on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation.)
history
Subject: history
s/ true, screw, tew.
A 20 gauge____ guide monoptic coaxial system was employed to obtain 2 core biopsies of the lesion
OB history
Subject: OB history
CAMT- In my BOS second edition- page 290: Separate GPS sections by commas:
G4, P3, A1 
History of?
Subject: History of?
Could the dictator be saying "history of" cholecystectomy," instead of "her 'seri' cholecystectomy?
history of **leg TB**? sm
Subject: history of **leg TB**? sm
it's on a numbered list so i really dont have anything else to work on. THANKS!
not sure but her history is.....
Subject: not sure but her history is.....
pt had a surgery recently from a MVA and had several broken bones, also history of hypertension, diabetes and peripheral vascular disease. thanks
??? not sure, not really any history
Subject: ??? not sure, not really any history
sounds just like Caprix
Social history
Subject: Social history
I forget the proper transcription for this regarding numbers--
Occasional tobacco use, 1-2 half-packs per day.
Should 1-2 be spelled out and is half-pack hyphenated? Thanks a lot!
patient history
Subject: patient history
Patient presents with history of ***Lemure*** disease? s/l Lemirro
family history
Subject: family history
7yo girl with pneumonia. no family history of asthma or other chronic lung disease, immune deficiency or decreased sl-fertility.
H & P- history and physical...nm
Subject: H & P- history and physical...nm
m
history of ?ceilingectocies
Subject: history of ?ceilingectocies
Family history
Subject: Family history
Internal Medicine clinic notes:
Family history: S/L Vonastroms with accent on "strums" at the end of the word. Tape cuts out on the first part, but I can hear the strums at the end.
Thanks
s/l atremic history
Subject: s/l atremic history
PATH history
Subject: PATH history
Past history would cover you on all corners. Did the doc dictate any history? Unless she has significant OB/GYN pathology, which the doc would probably make note of, vaginal bleeding and "path" history don't go together. Hope that helped.
HELP-- pt has history of heroin and
Subject: HELP-- pt has history of heroin and
s/l aniculary drug use???????
It may be, but I don't know if she has a history of alcoholism. ..
Subject: It may be, but I don't know if she has a history of alcoholism. ..
I just left it blank for QA. Thanks for the suggestion, though.
Not really. Perhaps just "former history"?? nm
Subject: Not really. Perhaps just "former history"?? nm
x
pro forma history? See ref.
Subject: pro forma history? See ref.
Main Entry:pro for*ma
Pronunciation:(*)pr*-*f*r-m*
Function:adjective
: done or existing as a matter of form
says s/l history of DVD/PE ? - on anticoagulation
Subject: says s/l history of DVD/PE ? - on anticoagulation
Psychiatry - history of s/l TEE-H-SHE (sm)
Subject: Psychiatry - history of s/l TEE-H-SHE (sm)
history of s/l TEE-H-SHE times 2 years, ectasy times 2 years, and significant alcohol use. ??? TIA
Patient with history
of femoropopliteal bypass graft. Pulses palpable at s/l PTTP???? I am brain dead here. TIA
could it be history of hypertension?
Subject: could it be history of hypertension?
nm
history of pneumonia?
Subject: history of pneumonia?
Need help with two words please.
History of pneumonia and s/l bi-e-ma status post s/l e-cor-ti-cation
Bony______ (history)
Subject: Bony______ (history)
Chief complaint: Hit the wall with hand.
maybe infectious history
Subject: maybe infectious history
surgical history s/l all-tee
Subject: surgical history s/l all-tee
Patient is being seen for balance problems. There is a lot of focus in the report on various tests and her previous tethered cord, lumbar stenosis, laminectomy, etc.
Past surgical history includes: "repair of a spinal fluid leak and (s/l all-tee) then the lumbar spine fusion."
Any ideas as to what the all-tee might be? At first I thought it was the doctor stumbling over her words, but upon re-listening, I'm not so sure!
as in he personally has history of.... NM
Subject: as in he personally has history of.... NM
7-year history.....
Subject: 7-year history.....
I get confused, too! well-defined hypen; the hyphen is well defined. That is how I think of the hyphens, but I'm no BOS guru - just been in the biz for a long time.
I do not in surgical history. I only
Subject: I do not in surgical history. I only
expand it if in an op report heading of Procedure Performed:
Surgical History
Subject: Surgical History
"significant for hip replacement, "appy"????
1-year history
Subject: 1-year history
How would you type the patient has a 1-year history of pain....tia.
Pt with history of LGSIL Pap sm
Subject: Pt with history of LGSIL Pap sm
A: History of LGSIL Pap, s/l ***full colpscopy*** with 1 directed biopsy obtained.
I don't have much experience at all in anything related to GYN procedures and not sure if there is a distinction between a colposcopy and a full colposcopy - the only other thing it s/l is ***for colposcopy*** with 1 directed biopsy obtained.
Hope I made sense here. Thanks for any help.
Patient has history of anemia..sm
secondary to s/l "naneocrosis". Any suggestions?
Past medial history
Subject: Past medial history
The patient is admitted from the clinic where CT visuals showed recurrence of the disease.
I'm not sure if that's what the doctor is saying. Does it sound right?
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