For Medical Transcriptionists?

Question

I'm finishing a medical transcription training program, but I'm trouble with the HEENT section of H&Ps. I'm not sure which terms should be in all caps. Can anyone share a guideline for this?
thanks.

While you're here, is there supposed to a hyphen between the letters and numbers in "S3, S4, or murmurs."?

Answer 1

In the HEENT section, the terms which should be in all caps (and this varies based on the specifics that the individual account asks for) should be PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extraocular movements intact), TMs (tympanic membranes) usually followed by intact, and EACs (external auditory canals) usually followed by clear.

Unlike the person above, I almost always type an H&P within a consult note but sometimes the format varies.

Edited to add -- No S3, S4, or murmurs -- They should be typed together with a comma between each.

Answer 2

The HEENNT is under the PE (physical exam) portion of a Consultation. There is an HPI on this form, which stands for History of Present Illness.

The order on the Consultations I use are:

HPI;

PMH (past medical history), under which you have Medical, Surgical, Allergies, and Medications;

Comprehensive Review of Systems...;

SH (social history)

FH (family history)

PE (physical exam), under which you have: Blood presure, Weight, General, Skin, HEENNT, Neck, Chest, Heart, Abdomen, Genitalia, Lymphatic, Neurologic, Musculoskeletal

A (assessment)

P (plan)

There is not a "P&E" on the Consultation forms I use. And, my forms for Clinic Notes have: S (subjective), O (objective), A (assessment), and P (plan). This is sometimes called the SOAP form.

Regarding your question about "S3, S4". These are synovitis ratings and should be typed with a hyphen: S-3, S-4. Tenderness ratings should also be typed with a hyphen: T-1, T-3.

But, if you are typing spinous processes, you do NOT use a hyphen: T4, C3, L1 are some examples.

The word murmur does not have a hyphen.

If your medical transcription company did not furnish you with a "Standardization Manual" that outlines their guidelines for transcription, then I feel sorry for you. If they did, then your answers would be found in this guideline.

Once you get into "live work," I'm told, individual preferences by the physicians would take precedence over your training guidelines. But, for training purposes, the spelling of the terms as is listed here is the way they should be...