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how about typing Past Medical History heading and then typing what he says under the heading nm

Posted By: NYMT2 on 2009-03-05
In Reply to: Heading? - Kristi

Subject: how about typing Past Medical History heading and then typing what he says under the heading nm

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H&P heading help again.. Past Medical History
Subject: H&P heading help again.. Past Medical History

dictator says: Past medical history for hypertension. Past surgical history is arthroscopy of his right knee. Allergies are to Demerol and Penicillin. Do I put Headings over each one and keep the exact dictation like this:  PAST MEDICAL HISTORY (type under this title) Past medical history for hypertension OR just Hypertension. Other part of my question.  ROS subheadings: dictator says this: Cardiovascular has a history of hypertension.  do I need to put a colon in there and cap the Has? or leave as I have typed in bold? Do I add a subheading of GI/GU: for this sentence - No GI/GU problems. Does this sentence also need colon?  Musculoskeletal I stated in the HPI. No neurological or hematological discorders.  Thanks for any help, sorry if these seem like dumb questions...but I really need the help.


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. 
Past medical history
Subject: Past medical history

Under history of present illness he has that the patient has a history of IV drug abuse.


Past medical history: IODINE ALLERGY WITH SHORTNESS OF BREATH AND HIVES FOLLOWING IV SPREE THREE YEARS PTA.


Could that be what he's saying? Thanks.


under past medical history...
Subject: under past medical history...


Past medical history
Subject: Past medical history

Surgeries: Small bowel obstruction, THA/BA for cholecystectomy.


I'm not sure if he said BA or BA with another letter on the end. Help! Thanks.


past medical history
Subject: past medical history

This is the only information I have and it sounds like **Ba-dex Ex-lo-dian** under past medical history. Thanks for any suggestions!
Past medical history
Subject: Past medical history

Past medical history: Positive for arthritis, asthma, and "vic-in-plant-ous". She also has a dystonia that has been longstanding. This is on an ortho note, so this is the only thing said about this. Thanks for checking it out!
Past medical history help
Subject: Past medical history help

Under past medical history he states "Basal cell **and blue** carcinoma.


My apologies if this is something simple, but this is what it sounds like and I am not finding anything to point me in the right direction. Thanks!


past medical history?
Subject: past medical history?

If it is past medical history, could he be saying something like history of Legg's disease. Try looking at it that way.
What is in Past Medical History
Subject: What is in Past Medical History

That could help determine what the drug is for.
What is the past medical history? - nm
Subject: What is the past medical history? - nm


what's in the past medical history?
Subject: what's in the past medical history?


past medical history of thrash?
Subject: past medical history of thrash?

The patient is a 3 1/2 month old with a past medical history of ____.  S/L thrash
CARDIO Past medical history
Subject: CARDIO Past medical history

CABG 1998 and s/l CVAA SPVD status post right lower extremity amputation and hypertension.


Thank you


Deborah


In past medical history - the only thing
Subject: In past medical history - the only thing

listed is s/l Berjay's disease.


I've Googled every spelling I can think of and have come up blank 


He only mentioned it once in the past medical history...(sm)
Subject: He only mentioned it once in the past medical history...(sm)

Didn't even mention it again in the final diagnoses with the rest.  I think the poster below found it.  Thanks.
the doctor said that only in the past medical history :(
Subject: the doctor said that only in the past medical history :(


Past medical history s/l ben rr ma gene
Subject: Past medical history s/l ben rr ma gene

Under past medical history, dictator is saying s/l ben r r ma gene.  Or banner arma gene.  ??? 


Patient also has hypertension, dyslipidemia, asymptomatic stroke, sleep apnea, renal insufficiency.  Any ideas?


No clues in the past medical history? n/m
Subject: No clues in the past medical history? n/m

X
afib dictated as past medical history...
Subject: afib dictated as past medical history...

how do you write that out?


atrial fibrillation, afib? 


Too early for me right now.


Can you give the diagnosis or past medical history.
Subject: Can you give the diagnosis or past medical history.

Do you anything that this medication might be for?
Past medical history: Significant for s/l uterine CA.
Subject: Past medical history: Significant for s/l uterine CA.


doc is dictating past medical history and said exactly what was quoted with nothing else regarding i
Subject: doc is dictating past medical history and said exactly what was quoted with nothing else regarding it. nm

Thanks.
Need help with past medical history list s/l - please see message
Subject: Need help with past medical history list s/l - please see message

Bipolar disorder, dyslipidemia, hypertension, type 2 diabetes, s/l pax dee a tosis (?ptosis).

That what it sounds like!! Thanks for any help!
Past Medical History: Significiant, only as noted...??
Subject: Past Medical History: Significiant, only as noted...??

JMO
Past medical history: Bilateral pleural effusion, then s/l
Subject: Past medical history: Bilateral pleural effusion, then s/l

chronic stasis - period.  Would that be right?
Child with shoulder injury with past medical history of
Subject: Child with shoulder injury with past medical history of

s/l spheriocytoma. The closest I found was esthesioneurocytoma, but he is not saying "neuro" in between, and that he takes folic acid. Any ideas? Unfortunately, the doc never makes mention again about this diagnosis anywhere on the report.
in list of past medical history....hypothyroidism secondary to sm
Subject: in list of past medical history....hypothyroidism secondary to sm

s/l "dis-turds" versus anemia.  The doc is is seriously mumbling but I think he says something like this.


foley site in the s/l avera? this is listed in past medical history
Subject: foley site in the s/l avera? this is listed in past medical history


please help! Past medical history includes s/l spilling? cardiac enzymes. Thanks!
Subject: please help! Past medical history includes s/l spilling? cardiac enzymes. Thanks!


Past medical history significant for s/l wrekal sinus excision
Subject: Past medical history significant for s/l wrekal sinus excision


pleural of decubitus is decubitus in Dorlands Medical Dictionary. I have always been typing decubiti
Subject: pleural of decubitus is decubitus in Dorlands Medical Dictionary. I have always been typing decubiti as the pleural. Oops. nm


cor is the heading. sm
Subject: cor is the heading. sm

Some say Cardiac:   S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.


 


What heading would you use?
Subject: What heading would you use?

Okay to add headings on OP report.  MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....


 


Thanks.


Under what heading would you SM
Subject: Under what heading would you SM

put inguinal hernia in a PE?  Would it be abdomen?


 


TIA


EKG can be a Heading
Subject: EKG can be a Heading

I would put under EKG alone as


 

EKG:  EKG today show no ST wave changes.
Heading?
Subject: Heading?

This is for a psych. consult.  After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.


I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records.  Past Medical History, yes, but not the other.  Any ideas?


Oops, used same heading, need help
Subject: Oops, used same heading, need help

Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".



Thanks


IV abbreviated in heading
Subject: IV abbreviated in heading

Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?


under abdomen heading
Subject: under abdomen heading

s/l "the PICC was created" or "the tic was created"


Angie


Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?

I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with

s
I think doc left heading out sm
Subject: I think doc left heading out sm

He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.


What would be asymmetrical here?


 


I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm

One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?

Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.

Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:

ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.

Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!

Needless to say, it stresses me out a bit. Any advice is definitely appreciated!

A lot of facilities use the heading
Subject: A lot of facilities use the heading

"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?

Just wondering under what physical exam heading other MTs put this finding under.

TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.

I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they

want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?

I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
Sorry, this should have been under heading Physical Examination.
Subject: Sorry, this should have been under heading Physical Examination.