doc reviewing a record. Any ideas? Available for review is a s/l “fair-row” seven page typewritten
Posted By: MSteph on 2008-12-21
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Record Review: S/L
Subject: Record Review: S/L
'gluteus piriformis intentious fascia lata'
Doc doing review. Any ideas? sm
Subject: Doc doing review. Any ideas? sm
Available for review is a s/l “fair-row” seven page typewritten report.
The exact reference is on page 196, see my post below, not page 6..nm
Subject: The exact reference is on page 196, see my post below, not page 6..nm
nm
It is Review of Systems and not Review of Symptoms.
Subject: It is Review of Systems and not Review of Symptoms.
after reviewing the s/l Ř%", the patient was brought to the operating room
Subject: after reviewing the s/l Ř%", the patient was brought to the operating room
after reviewing the s/l "4%", the patient was brought to the operating room
No, not a medical record, but it is being put
Subject: No, not a medical record, but it is being put
While I realize it is the OP's responsibility to doublecheck whatever answers received here, and it's fine to be lazy in any other posts on the board, but IMO, it's still a good idea to give correct answers -- spelling, capitalization, and all -- when providing word help. Otherwise, if the OP is also "lazy" it will end up in a medical record the wrong way. Not major in this case, but could be in others ...
Just my opinion, of course.
It's weird because in his record, it's "hypernephrosis" and .....
Subject: It's weird because in his record, it's "hypernephrosis" and .....
I just had to put abdominal pain. 
I think MAR is the Medication Administration Record. nm
Subject: I think MAR is the Medication Administration Record. nm
s
Stands for medication administration record
Subject: Stands for medication administration record
s/l sea-fair fibromyalgia----nm
Subject: s/l sea-fair fibromyalgia----nm
s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
Subject: s/l "cyberun" Maybe some type of chart record? Dialysis patient sm
States: "Review of report in ____ suggests..." Again later in dictation: "Although this is not charted in ____. "
there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
Subject: there is the abbreviation MAR docs dictate for medication administration record, but not sure...sm
if that's it? This is usually dictated when they don't want to list the entire medication list so refer to the MAR that is in the chart.
It's usually good, fair, or poor. nm
Subject: It's usually good, fair, or poor. nm
s
Another one--this isn't fair. "hilan cells"?
Subject: Another one--this isn't fair. "hilan cells"?
Patient with abdominal pain. Urinalysis with bacteria results and then he says "8-12 hilan cells". Yet again, this is something I can't find anywhere in relation to Gastroenterology or even any urinalysis results. Sounds like "Hilan, or "Highland" cells.
Pherogrin M? Sounds like fair-o-grin M
Subject: Pherogrin M? Sounds like fair-o-grin M
nm
Pherogrin M? Sounds like fair-o-grin M
Subject: Pherogrin M? Sounds like fair-o-grin M
nm
Hemodialysis medication s/l fair in zimplar TIA.nm
Subject: Hemodialysis medication s/l fair in zimplar TIA.nm
my doc told me not to use neosporin on my fair-skinned child.
Subject: my doc told me not to use neosporin on my fair-skinned child.
Son had cellulitic infection a few years ago in his diaper area. Doc tole me to only use polysporin on fair skin. Not sure what the significance or reasoning was but the neosporin made it worse and the polysporin cleared it up quickly.
is it fair to guess a slip of the tongue, i.e. just saying the Mc part as a stutter after saying McM
Subject: is it fair to guess a slip of the tongue, i.e. just saying the Mc part as a stutter after saying McMurray?
I'd guess you are right that he did mean Lachman, just got carried away with the Mc part.
Patient has fair to s/l "low fiber" cardiac prognosis. MD mumbles. TIA
Subject: Patient has fair to s/l "low fiber" cardiac prognosis. MD mumbles. TIA
x
X-Ray Review help
Subject: X-Ray Review help
X-RAYS: Review of her x-rays today show that she has a three-part fracture of her proximal humerus with head rotated and the (something ending with) 'osity' displaced. 
Thanks
Thats all in Review of systems.
Subject: Thats all in Review of systems.
Thanks though!
Under review of systems...
Subject: Under review of systems...
Sounds like dictator is saying:
Abdomen: Soft. Flat. Obese. Pressure: Soft. Obese. No point of splenomegaly was noted.
However, it doesn't seem to me that this would fit. He may be saying another heading instead of pressure but it is too jumbled to tell. 
Also this may be: No signs of [something] or splenomegally is noted.
Thanks in advance!
Review of Systems
On Review of Systems, he's saying . . ."@#$#&*&(" : No recent skin rash. and then something else "@#$#$" : No anemia or lymph gland problems. Psychiatric - No recent depression. Can anyone tell me what these headings could possibly be? I can't even get enough to give you a "sounds like".
In Review of Systems
Subject: In Review of Systems
There is no history of diabetes, polyuria, polydipsia, seizure, stroke, TIA, loss of strength or sensation, or DVT s/l pulmonary mesin around level bleeding.
It might be 'pulmonary embolism' but I might just be wanting to hear that, it's kind of a stretch. But the rest...
Any ideas??? Thanks.
Review of systems
Subject: Review of systems
Review of systems include shortness of breath and s/l ricacaria?? Anyone ...help???
Q in Review of Systems
Subject: Q in Review of Systems
When the doc says - Rest of systems: Negative. do we write it that way or list the systems with Negative next to them all?
Do you want to know was ROS is? Review of systems.
Subject: Do you want to know was ROS is? Review of systems.
review of systems twice
Subject: review of systems twice
The doc says his normal ROS. At the end of his thought he pauses for a LONG TIME and then says "ROS, on the line, otherwise negative."
So should I do it like I have below or what are your suggestions?
REVIEW OF SYSTEMS: blah blah blah.
A review of systems is otherwise negative.
In review of systems he says,
Subject: In review of systems he says,
"no fevers, chills or sweat s/l size-or-trizer?
Review of Systems
Subject: Review of Systems
Of course...You are correct. I was typing too fast. :-)
Review of Systems
Subject: Review of Systems
I knew that is what you meant.
It is indeed "is"....as review is single.
Subject: It is indeed "is"....as review is single.
 Boy, if that don't make sense, nuthin' does! I fried my brain years ago though...a product called White-Out...hey, it was the 80's and what else was there to do in typin' class?
possibly - I am sending for review
Subject: possibly - I am sending for review
Ever heard of this? Xray review
Subject: Ever heard of this? Xray review
Review of his x-rays today show no evidence of any s/l 'ab-lateral compartmental arthritis.
wasn't sure if this was an actual word (short for something) or if he possibly tumbled over his words and just meant to say lateral compartmental . . .
thanks for the help.
Disregard - I marked for QA to review.
Subject: Disregard - I marked for QA to review.
Disregard - I am sending for review
Subject: Disregard - I am sending for review
Not saying ROS of review of systems is negative? nm
Subject: Not saying ROS of review of systems is negative? nm
s/l taw-tur-tile CRP. Lipid lab review.
Subject: s/l taw-tur-tile CRP. Lipid lab review.
 One of those days when I can't understand anyone!
BOS page 282
Subject: BOS page 282
x
On page 172
Subject: On page 172
Mine still reads as I quoted above, and I see no questions and answers, only examples. Still says follow-up is an acceptable alternative. Also, account preference trumps BOS, and I have accounts for which the expectation is follow-up.
Nothing new. See BOS page 16. nm
Subject: Nothing new. See BOS page 16. nm
x
please help me with page # in bos 2nd ed., where it says
Subject: please help me with page # in bos 2nd ed., where it says
to use 1, 2, 3 rather than spell out one, two, three -- I KNOW it's in here but i can't find it :(
(probably because I'm looking :(
and no, i'm not testing for anything -- i'm fighting a QA review
thx
Per BOS, page 200...sm
Subject: Per BOS, page 200...sm
height
Express with numerals, as indicated below.
Write out nonmetric units of measure; do not use the symbols " and ' for inches
and feet.
Note: There is no comma between units of the same dimension, so there is no
comma after feet in the following example:
Height: 5 feet 8 inches.
BOS Page 324 says...
Subject: BOS Page 324 says...
plus/minus:
Express as plus or minus or plus/minus, not +/- or + except in tables or test results.
Hope that helps!
Without, page 283 of BOS II. nm
Subject: Without, page 283 of BOS II. nm
s
BOS II page 146 - says to use n.p.o. nm
Subject: BOS II page 146 - says to use n.p.o. nm
s
BOS page 370
Subject: BOS page 370
stat
BOS 2, page 196.....
Subject: BOS 2, page 196.....
gray (Gy)
The Internationaal System Unit of absorbed dose of ionizing radiation. Equal to 1 joule per kilogram of tissue.
Abbreviation: Gy (no period)
Other review of systems showed s/l OS negative
Subject: Other review of systems showed s/l OS negative
Other "review of systems" ____ showed s/l "OS" negative.
here's a good web page
Subject: here's a good web page
http://www.pharma-lexicon.com/
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