clinic note help
Posted By: rachel on 2006-11-14
In Reply to:
Subject: clinic note help
 Patient is accompanied by her husband today who is very concerned regarding recent symptoms of numbness and tingling in the lateral aspect of the left and right arm. ***This is been ongoing x 2 to 4 weeks.**** . is this the correct way to transcribe this? The last sentence is the questionable.... thanks for all your help!!
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clinic note
Subject: clinic note
thanks for your help, I am a new MT and I am a little confused with some things. thanks again!!!
clinic note
Subject: clinic note
the doctor says "this has been ongoing times 2 to 4 weeks" i was not sure how to transcribe that.
clinic note
Subject: clinic note
Your a wonderful help!!!!
clinic note help
Subject: clinic note help
does a doctor usually use the word relay example: Patient mainly relays that she has trouble falling asleep at bedtime. 
clinic note
Subject: clinic note
Yep, it is a clinic report and the clinic does not want abbreviations spelled out. In samples of their reports I was given h.s. was never spelled out, however, I could not find one that stated q.h.s. so I was unsure of the space. Thanks for your help.
Pain clinic note - sm
Subject: Pain clinic note - sm
inpatient s/l catimmune infusions
No, the note I am typing is for a geriatric clinic. Thank you!
Subject: No, the note I am typing is for a geriatric clinic. Thank you!
x
Doing cardiac transplant clinic note, patient with SM
Subject: Doing cardiac transplant clinic note, patient with SM
cardiac allograft vasculopathy. Last s/l alamac or LNAPs was 17 on September 5. Last PRAs in July of this year were unremarkable. Note patient has had s/l LNAPs of 34 and 27 TIA
doing a wound care clinic note. is sluffed loose skin
Subject: doing a wound care clinic note. is sluffed loose skin
correct??? the word "sluffed", sound familiar to anyone? thanks
Sarcoma clinic note - patient found to have coag-neg staph instead
Subject: Sarcoma clinic note - patient found to have coag-neg staph instead
-The plan is to start her on antibiotics as per s/l ID's recommendation and follow her closely.-
This doesn't sound like the name of any of the doctors involved, so I thought it may be a protocol that I'm not familiar with. Thanks for your help!
Quick question - Clinic note, doc dictates the word pantalones - Spanish for pants. Would you... sm
Subject: Quick question - Clinic note, doc dictates the word pantalones - Spanish for pants. Would you... sm
type as dictated, or change it to "pants" ? My first instinct was to look up the word "pantalones" online to make sure I spelled it correctly, and type as dictated. Then I thought, for clarity (and future readers of the note who might not speak Spanish - though I think you could figure out what is meant by reading the report), should I change it to "pants" ? She does say "pantalones" in kind of a "cute" way. She also yawns loudly at the end, so maybe she's a little loopy.  LOL Opinions?
sorry, it's not the leukemia clinic. It's the lymphoma/myeloma clinic. I'm still stumped!
Subject: sorry, it's not the leukemia clinic. It's the lymphoma/myeloma clinic. I'm still stumped!
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Clinic name?
Subject: Clinic name?
I dont know if you can post it, but where is your acct at? I ask because I just googled steroid and Kleinert Kutz and it seems to be a hand care center. Might give it a try!
It would actually be the name of the clinic
Subject: It would actually be the name of the clinic
however, without a list of clinics in the area MTs have no way of knowing if it just a general term or the actual name. I always capitalize to be on the safe side, have not been told not to yet.
pain clinic
Subject: pain clinic
The patient is scheduled for a percutaneous s/l racks or rax procedure of the lumbar spine. Any ideas?
Oops, clinic
Subject: Oops, clinic
s
Rare? Every clinic I do uses them. nm
Subject: Rare? Every clinic I do uses them. nm
nm
Pain clinic - need help with s/l - thank you.
Subject: Pain clinic - need help with s/l - thank you.
Patient has neuropathic pain and is on Lyrica and Zonegran.
"I suggest that he also try a nutritional supplement, s/l gama-lin-a-la-ic acid, for neuropathic pain."
fertility clinic
Subject: fertility clinic
allow sperm cells to be placed on a hyaluronic _________.
Do not cap. Cap only if it is a specific clinic, name given....nm
Subject: Do not cap. Cap only if it is a specific clinic, name given....nm
nm
It's a GI clinic and it doesn't look like she has had cancer.
Subject: It's a GI clinic and it doesn't look like she has had cancer.
I
Duh on me. Go with Endocrine. Our clinic used the ROS I referenced. nm
Subject: Duh on me. Go with Endocrine. Our clinic used the ROS I referenced. nm
New to pain clinic tx - does this sound right.
Subject: New to pain clinic tx - does this sound right.
The examination of the cervical spine showed limited extension, which is painful, as well as limited lateral rotation, which is also painful. Flexion is very limited due to pain.
s/l Axillary is positive at approximately C5 on the right in the cervical paraspinous region.
It isn't very clear and really sounds more like axilony (does not s/l he's saying axial nerve). Axillary is the only thing that makes sense to me. Does anyone know if there's another possibility? Thanks :)
I use to do an oncology clinic and they wanted it as T3 NX
Subject: I use to do an oncology clinic and they wanted it as T3 NX
Pain clinic help needed. please sm
Subject: Pain clinic help needed. please sm
In the past, patient has tried tramadol, Percocet, Vicodin, and Darvocet. She has never used an anticonvulsant, a tricyclic antidepressant, or s/l sympatholitic.
Rheumatology clinic labs ... psm
Subject: Rheumatology clinic labs ... psm
Patient is toddler who has had joint stiffness.
On initial blood tests, he had 4 IgG bands per line.
Does this sound correct? Thanks.
I worked for an orthopedic clinic and their
Subject: I worked for an orthopedic clinic and their
preference was L2-L3.
Pt is followed in Cancer CLinic for s/l MGUF. sm
Subject: Pt is followed in Cancer CLinic for s/l MGUF. sm
A lumbar puncture showed increased CSF protein and SPEP showed two gamma spikes of monoclonal IgM kappa type. They state that he is in cancer clinic, presumably for follow-up for this mguf.
ambulatory ER medi clinic?
Subject: ambulatory ER medi clinic?
The patient was seen in an "ambulatory ER medi clinic" while out of town. That doesn't look right to me. Can I get a more experienced opinion on that phrase? Thanks.
Pelvic pain clinic today
Subject: Pelvic pain clinic today
Hello all! I have been asked to fill if for a pelvic pain clinic this week so this might not be the last time I'll have to ask for help since I'm not used to this terminology!
Here is the question - on an endometrial biopsy:
Cervix ___ with tenaculum. Swabbed with Betadine. Sounded to the depths of 10 centimeters. Good specimen obtained.
At first I though he was saying "washed" but then looked up tenaculum and that appears to be a scissor-type instrument that is used for stretching so I don't think that is the right word. Thanks for the help!
Not saying DNA probe for BV etc? Our clinic used that generic term. nm
Subject: Not saying DNA probe for BV etc? Our clinic used that generic term. nm
Pain clinic medication s/l. Please see message.
Subject: Pain clinic medication s/l. Please see message.
Patient doing well now six months post-op, is on MS Contin 15 mg b.i.d., one-half of immediate-release morphine 15 mg at midday, s/l pol-e-sor 200 mg q.a.m. She takes Neurontin and Risperdal 1 mg. She ambulates with a cane and is improving on aqua-therapy.
?? Could be medication to aid in weaning off the narcotics.
Pain clinic help needed - please see message
Subject: Pain clinic help needed - please see message
Patient has sacral fracture.
Medications: Cozaar 50 mg p.o. b.i.d.; Lipitor 10 mg p.o. q.h.s.; Lexapro 20 mg p.o. q.a.m. (prescribed by psychiatrist Dr. Laakso); Fosamax 70 mg p.o. q. week; Sinemet 25/100 q.2 h; Sinemet R at bedtime (could not find Sinemet R, but that's what he says).
I have asked her to increase the OxyContin to 10 mg in the morning and 20 mg in the evening, and she can continue to use the s/l sure-lacking medication for breakthrough pain.
Pain clinic dictation is so hard to me. nm
Subject: Pain clinic dictation is so hard to me. nm
Haven't done clinic in 4-ever and could not remember that! Thanks for posting! nm
Subject: Haven't done clinic in 4-ever and could not remember that! Thanks for posting! nm
 nm
I have herad of Caspar pins in my Ortho clinic.
Subject: I have herad of Caspar pins in my Ortho clinic.
x
Information provided by the Reference Lab at the Cleveland Clinic
Subject: Information provided by the Reference Lab at the Cleveland Clinic
Test Name: Reticulocyte Count (Ordering Mnemonic: RETIC) |
|
Methodology:
| Automated Cell Counter |
Includes:
| Reticulocyte percent; Absolute Reticulocyte Number |
.
|
Reference Range:
| Reticulocyte:
Range: 0.5 - 3.2 %
Absolute Reticulocyte Number:
Range: 0.022 - 0.156 M/uL
|
|
| |
| |
| |
| |
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No not testing...just been a long time...use to ER and clinic work...not this..lol
Subject: No not testing...just been a long time...use to ER and clinic work...not this..lol
Thank you so much. It is going to take me awhile to get back in the swing of things....Its been years since I have done anything else....thanks again!
I agree about him making it up. This clinic doesn't want blanks
Subject: I agree about him making it up. This clinic doesn't want blanks
nm
Patient admitted from the sickle cell clinic, s/l....
Subject: Patient admitted from the sickle cell clinic, s/l....
s/l the six route, and started on.....
Does this make sense?
Thanks.
Pain clinic medication - s/l esoporific medications.
Subject: Pain clinic medication - s/l esoporific medications.
He is not taking any stimulants currently. The patient feels that his moods cycle too rapidly when he is put on stimulants to counteract his s/l esoporific medications.
*Apolic* Health Clinic? In NJ for bipolar disorder
Subject: *Apolic* Health Clinic? In NJ for bipolar disorder
Pedi Genetics clinic -pt "has a normal (s/l) Territype
Subject: Pedi Genetics clinic -pt "has a normal (s/l) Territype
cyst removed from the preauricular area. Also pt is doing well in school. I've looked in my refs, online, and nothing. It's probably something easy 
Please help.
I know the general rule, been MTing 15 years, thought clinic was maybe different.
Subject: I know the general rule, been MTing 15 years, thought clinic was maybe different.
Pt in Pulmonology CLinic had a "baps" biopsy confirming pneumoconiosis. nm
Subject: Pt in Pulmonology CLinic had a "baps" biopsy confirming pneumoconiosis. nm
noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy
Just wondering if there is any general rule about transcribing noteworthy.
Also, status post; status-post.
Thank you.
New to clinic work. I'm thinking nebulizer meds, but she didn't list them
Subject: New to clinic work. I'm thinking nebulizer meds, but she didn't list them
I have always been told to capitalize when a specific center, ER, or hospital/clinic is mentioned.sm
Subject: I have always been told to capitalize when a specific center, ER, or hospital/clinic is mentioned.sm
Otherwise it is kind of like a generic term, the patient can follow-up in travel care clinic of choice. I hope this helps out!
Op note ref. SM
Subject: Op note ref. SM
http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note
? pulse ox 99% on room air which is normal per ______ interpretation.
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