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Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm

Posted By: Tracey on 2008-09-26
In Reply to: Never heard a doc say anything but the acronym form - moon1010

Subject: Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm

nm


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

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Then ask your manager to find out from the clinic manager.
Subject: Then ask your manager to find out from the clinic manager.

I can't imagine they won't at least attempt to find out.
reply to type of exam look under my LAB from debbie
Subject: reply to type of exam look under my LAB from debbie


I wouldn't, but maybe you should ask your manager
Subject: I wouldn't, but maybe you should ask your manager


my manager says always with the dash
Subject: my manager says always with the dash


thanks for trying. I will post what manager says. nm
Subject: thanks for trying. I will post what manager says. nm

nm
manager says it was "crinkle" nm
Subject: manager says it was "crinkle" nm

nm
patient care manager? nm
Subject: patient care manager? nm


Practice Care Manager?....nm
Subject: Practice Care Manager?....nm


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Subject: manager says it is "waiters sign" nm

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thanks to all. Manager says it is turf liner. nm
Subject: thanks to all. Manager says it is turf liner. nm

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believe it or not... it was morphology per manager. Thxs anyway. nm
Subject: believe it or not... it was morphology per manager. Thxs anyway. nm

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manager just emailed me back. sm
Subject: manager just emailed me back. sm

she couldn't find it on google either but she remembers she has had it before and found it in an ortho book. It wasn't in mine though??!!
Customer Care Manager - your supervisor - nm
Subject: Customer Care Manager - your supervisor - nm

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that's all I could find also. Manager says Roger-Mann. I have an email in to her as to where sh
Subject: that's all I could find also. Manager says Roger-Mann. I have an email in to her as to where she found that. Thanks for the responses.


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?

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Subject: question about assessment

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Subject: Assessment: Vaginitis DX. I never heard of DX?? thanks


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Subject: Under assessment: UNCOMPELLING EMG results

Is uncompelling a word?


Or is it noncompelling?


Thanks!


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

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Subject: Geriatric Assessment Unit

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

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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.

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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..

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


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Subject: CIWA-Clinical Institute Withdrawal Assessment

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

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


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CIWA score (Clinical Institute Withdrawal Assessment) NM
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Pt had itching she treated with OTC Monistat. Assessment s/l vagini ovitis symptoms.
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