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just a thought..how about no change to previous?

Posted By: mm on 2008-12-05
In Reply to: "No change to p-fish." This doctor says this after the list of meds and before allergies. Th - jen

Subject: just a thought..how about no change to previous?




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No previous MI. Tx anyway! nm
Subject: No previous MI. Tx anyway! nm

xx
You might not like this one, but I would go by what QA said on the previous report. This way you hav
Subject: You might not like this one, but I would go by what QA said on the previous report. This way you have verification in writing of why you chose to keep it this way in case you are questioned on your choice of interpretation. I know we are looking for common sense but we are transcriptions and as we know that is not even close to always being the case in MD dictations.


could it be part of previous ??
Subject: could it be part of previous ??

could it be the dosing of the med before and you think he is going to the next number in the list? The "million" part is making me question this. Otherwise I have no idea. I hope you find your answer!
a previous post
Subject: a previous post

had this same sentence and it was "early satiety"
PS to clarify my previous post
Subject: PS to clarify my previous post

2 drugs:


s/l Cadawa NHCTC; I think it's for hypertension or hyperlipidemia.


s/l Rocethrin. For lesions? Could also be a pain med.


TIA!


 


I took this from a previous post about eponyms... sm
Subject: I took this from a previous post about eponyms... sm

According to BOS

eponyms

"While the use of the possessive form with eponyms remains acceptible, AAMT's preference is generally to drop the possessive form.

Apgar score, Babinski sign, Down syndrome, Gram stain, Hodgkin lymphoma.

Sometimes an awkward construction calls for use of the possessive form. This patient suffers from Hodgkin's."


Previous surgery for s/l lat pulley. TIA nm
Subject: Previous surgery for s/l lat pulley. TIA nm


aaaahh, my previous note should be SM!
Subject: aaaahh, my previous note should be SM!


did the link show up with the previous message?
Subject: did the link show up with the previous message?


Found previous note. It was Sigma...nm
Subject: Found previous note. It was Sigma...nm

nm
Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
Subject: Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,

any ideas? 


Thanks


Here's a link to a previous MTStars post
Subject: Here's a link to a previous MTStars post

on this same question.  Is this an ENT account?  The best thing would be see if you can get verification from the account, might be some name they have for their own conconction of Maalox, Benadryl and Xylocaine.  I've seen plenty of things misspelled in reports, even standards handed out by an account itself...
no, doesn't make sense....previous does
Subject: no, doesn't make sense....previous does

is this dictator an ESL? 


prior history of left shoulder pain?


previous history of left shoulder pain?


 


Found it in a previous dictation - it is Toronto.
Subject: Found it in a previous dictation - it is Toronto.


OOPS DISREGARD PREVIOUS THIS IS WAY IT IS WRITTEN?
Subject: OOPS DISREGARD PREVIOUS THIS IS WAY IT IS WRITTEN?

A trigger point injection at the right gluteus maximus trigger point was performed using mixture of 2 mL 2% Xylocaine and 1 mL 40 mg per mL Depo-Medrol.
Maybe referring to a stitch from the previous fistula??
Subject: Maybe referring to a stitch from the previous fistula??

x
Agree with previous poster. NEVER GUESS
Subject: Agree with previous poster. NEVER GUESS

x
I was able to locate a previous report which has 1, so I'll go with that
Subject: I was able to locate a previous report which has 1, so I'll go with that


pt with previous respiratory burns on prednisone and now s/l zo air. ?? nm
Subject: pt with previous respiratory burns on prednisone and now s/l zo air. ?? nm


Can you check a sample of doctor's previous
Subject: Can you check a sample of doctor's previous

c
patient with previous cesarean section..sm
Subject: patient with previous cesarean section..sm

preterm premature ruptured membranes, history of cervical prolapse and suspected s/l "cor amniotic"  (but her voice trails off at the end so have no idea what she is saying)
previous s/l attisoning syndrome secondary to steroid use
Subject: previous s/l attisoning syndrome secondary to steroid use


elevated liver functions, previous cholecystectomy.
Subject: elevated liver functions, previous cholecystectomy.

CT showed (S/L) ''normobilia''??  (have looked everywhere and cannot find--thanks for any help.)


capitalization rule after the previous word was a number.
Subject: capitalization rule after the previous word was a number.

how to capitalize the first letter of a new sentence if the last word in the previous sentence was a number?
He is referring to restless legs (from previous) but clearly says "skitchy". Ideas?
Subject: He is referring to restless legs (from previous) but clearly says "skitchy". Ideas?


previous s/l "graft trostomy tube placement" along with COPD
Subject: previous s/l "graft trostomy tube placement" along with COPD

previous s/l graft trostomy tube placement" along with COPD
He's saying bowstrung - I located a previous report where another doctor calls it a
Subject: He's saying bowstrung - I located a previous report where another doctor calls it a

nm
Hi - thanks for trying. I was lucky and found a previous report for patient and it is TBSO.
Subject: Hi - thanks for trying. I was lucky and found a previous report for patient and it is TBSO.

nm
Previous surgery includes lateral release of the s/l D&ACL reconstruction as well as shoulder.
Subject: Previous surgery includes lateral release of the s/l D&ACL reconstruction as well as shoulder.


Breast exam - She does have asymmetry in both breasts from previous s/l brain ansatangias. please sm
Subject: Breast exam - She does have asymmetry in both breasts from previous s/l brain ansatangias. please sm

I know that makes no sense at all but that's what it sounds like. This doctor is from Puerto rico. Up until this point, she has been pretty clear. Thanks for any help
Ophthalmology consult, this elderly gentleman has evidence of previous s/l a. phaci...the only
Subject: Ophthalmology consult, this elderly gentleman has evidence of previous s/l a. phaci...the only

thing that comes to my mind is phacoemulsification. The doc dictating this is so old and slurs so much that he should probably be retired. Any ideas anyone?
it is not ESL and I thought of warts but thought the same thing and it does not sound like a "t&#
Subject: it is not ESL and I thought of warts but thought the same thing and it does not sound like a "t"


There is evidence of previous caput costae, left thorax with good bony healings
Subject: There is evidence of previous caput costae, left thorax with good bony healings


s/l Bez or all in change
Subject: s/l Bez or all in change

shows the patient in sinus mechanism 66 beats per minute, normal intervals, normal axis.  Voltage criteria for LVH and s/l Bezoiorall is change in comparison to prior EKG dated
Thanks so much to both of you. I will change to 6, 90, and -1. nm
Subject: Thanks so much to both of you. I will change to 6, 90, and -1. nm


I change that to:
Subject: I change that to:

I change elicitable (which to my knowledge has never been a "real word" to "able to be elicited."  My doctor dictator thanked me for this once (I was suprised that he noticed).  I checked this out with several transcripitionists that I have worked with who have lots of experience and are CMTs and they also edit this word to "able to be elicited." 
I'm not CMT and I change that the same way...nm
Subject: I'm not CMT and I change that the same way...nm

      
cc to mL - do you change cc to mL
Subject: cc to mL - do you change cc to mL

according to AAMT or do you type cc


Thanks


 


Would you change this...

Would you change CT head to say head CT? The doctor says CT head.


 


Thanx


VR change
Subject: VR change

He should point it out to his supervisor because it is wrong. I don't care what QA says unless they can show me a resource where they got their information and it checks out. I would also point out to the client this fact. If they don't want to have their transcription correct and concise then I don't want their work. Right is right, wrong is wrong. I am really strong on this especially since the "new AAMT" has made all their "changes" and believe their BOS is the bible. It is not. Many of their "rules" are correct. Many of the are not. Research some of their changes and you will see just how over the top they have gone (it seems to be a control issue and they WILL cram it down your throat). I say that we all research on our own and go to reliable trusted sources that have been proven over time to be correct. The "New AAMT" definitely has not proven itself over time and incidentally they are not there for Americans anymore, they are there for the "overseas community." Humbug on them! Anyone know who could take the place of AAMT for American transcriptionits? After all, we are all Americans here and the language is English.
I would change it to this
Subject: I would change it to this

patients blood pressure readings at home daily have been 90 percent plus.  Would leave as is or change........looks wrong. 


Patient's daily at home blood pressure readings have been 90%+. 


they can change...
Subject: they can change...

depends on what the MD hears on auscultation; that being said, it usually is 3/6, 2-3/6...etc... six is the prime as there are standard 6 heart sounds and the first number being how many of the 6 they hear.
When did p.r.n. change to p.R.n. and why?
Subject: When did p.r.n. change to p.R.n. and why?

nm
I would change it to (sm)
Subject: I would change it to (sm)

CPKs as it appears these labs were done multiple times if they are dictating MBs. I hope I'm making sense.

I'd put, CPKs were high but his MBs were normal.
I would change it to
Subject: I would change it to

Mrs. Smith is a patient on whom I performed rhinoplasty. but that is just me.
Just like you have it, why change anything?
Subject: Just like you have it, why change anything?

x
I always change that to *in regard*..sm
Subject: I always change that to *in regard*..sm

as for toward/towards, afterward/afterwards......both are acceptable as you said per the dictionary......so it depends on the MD I'm working for...I have one that is a stickler so I give him afterwards and towards as he says them.
Exactly, that is why I don't understand, QA does the same with H&H, they change it H and H. Nm
Subject: Exactly, that is why I don't understand, QA does the same with H&H, they change it H and H. Nm

x
...or 'otherwise no overall change"..??? nm
Subject: ...or 'otherwise no overall change"..??? nm

s
I would change it to ൜ mEq K/L" sm
Subject: I would change it to ൜ mEq K/L" sm

The dictator is "slanging" the order. Since what they're ordering is K (potassium) and that is measured in mEq, and since it has a unit of measurement (mEq), then the "/liter" needs to be abbreviated to /L... imho (wouldn't it be nice if they dictated PROPER medication orders?) :)
I'd change to "mg," as well, but (sm)
Subject: I'd change to "mg," as well, but (sm)

the manufacturer's site would seem to indicate it should be hyphenated, as you originally had it.
http://www.jnj.com/index.jsp?content=product/brands/NEUTRA_PHOS.htm