Medical Transcription Phrases, Words, And Helpful Hints Medical Transcription Phrases, Words, And Helpful Hints

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  • Home
  • EEG Sample Reports For MTs
  • Physical Exam Words And Phrases for MTs
  • Colorectal Surgery Operative Samples
  • Orthopedic Operative Reports for MTs
  • Urology Operative Samples For MTs
  • Pediatric Discharge Summary MT Sample Report
  • Neurology Consultation Transcription Sample
  • Mental Status Exam Common Words and Phrases
  • Cardiovascular Terms For MTs
  • Sample ER Reports For MTs
  • Specialized Studies Terminology For MTs
  • EEG Terms For Medical Transcriptionists
  • Plastic Surgery Operative Samples for MTs
  • Urologic Procedure Words For MTs
  • Review of Systems Phrases And Words For MTs
  • Orthopedic Tests For Medical Transcriptionists
  • Pulmonary Operative Samples For MTs
  • Sample Pulmonary Function Tests For MTs
  • Polysomnography Sample Reports For MTs
  • Podiatry Operative Sample Reports For MTs
  • Electrophysiology Sample Reports for MTs
  • OB GYN Operative Samples For MTs
  • MRI Sample Reports For MTs
  • Lab Terms For Medical Transcriptionists
  • EMG Sample Reports for MTs
  • ENT Operative Sample Reports For MTs
  • General Surgery Operative Samples For MTs
  • Musculoskeletal-Ortho Words For MTs
  • Surgical Equipment And Instrument Terms For MTs
  • Wound Care And Pain Clinic Terms For MTs
  • Prenatal Tests And Baby Formulas For MTs
  • Surgery Op Report Terms For MTs
  • Dermatology Terms For MTs
  • Slang Terms Dictated By Doctors
  • Privacy Policy
  • Rehab And Physical Medicine And Podiatry Terms
  • Pulmonary Terms For Medical Transcriptionists
  • Psychiatric And Mental Status Words And Phrases
  • Ophthalmological Terms in Operative Reports
  • Ortho And Neurosurg Operative Terms for MTs
  • Ophthal Operative Sample Reports for MTs
  • OB GYN Surgical And Instrument Terms For MTs
  • Neurology And Neurosurgery Terms For MTs
  • CABG And Mastectomy And Newbie Terms For MTs
  • Neurosurgery Operative Samples for MTs
  • Nephrology Terms For MTs
  • Infant Physical Exam Words For MTs
  • Cardiovascular Operative Samples For MTs
  • GI Words For Medical Transcriptionists
  • ENT Surgical Words And Phrases for MTs
  • Rehab Discharge Summary MT Sample Report
  • Subtotal Maxillectomy ENT Operative Sample Report

Medical Transcription Phrases & Words Occuring in Review of Systems - For Medical Transcriptionists: 

REVIEW OF SYSTEMS: 

CONSTITUTIONAL: Appetite good. No weight change.

HEENT: Eyes: Cataracts removed. Mild glaucoma. He wears bifocals. ENT: No tinnitus or hearing loss.

CARDIOVASCULAR: As above.

RESPIRATORY: No cough or sputum. 

GASTROINTESTINAL: No abdominal pain. No constipation or diarrhea. No melena or bloody stools. 

GENITOURINARY: No hematuria or dysuria. Nocturia 2 or 3 times at night.

EXTREMITIES: Musculoskeletal: History of gout flaring up with warfarin.

SKIN: No pigmentation change, dermatitis or hair loss notable. 

NEUROLOGICAL: He has peripheral neuropathy. He has some mild atrophy in his fingers. No headache, paralysis or convulsions.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: No fever, chills.

HEENT:  No visual disturbance, no photophobia. No otalgia, no difficulty swallowing or speaking.

CARDIOVASCULAR: No chest pain.

RESPIRATORY: No shortness of breath.

GASTROINTESTINAL: Epigastric pain.

GENITOURINARY: No difficulty urinating. No urinary retention or urinary incontinence.

MUSCULOSKELETAL: No joint pain or swelling.

NEUROLOGIC: No paresthesias, anesthesias.

SKIN: No rashes.

PSYCHIATRIC: No hallucinations or delusions.

Review of systems otherwise negative. 

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fevers, weight change, headaches, visual changes, nausea or vomiting.

EYES: Denies cataract, glaucoma.

ENT: Denies nose bleeds, gum disease. 

INTEGUMENTARY: Denies healing problems or rashes.

VASCULAR: Denies peripheral vascular disease, deep vein thrombosis, and varicose veins.

CARDIOVASCULAR: Has hypertension. Denies arrhythmia, myocardial infarction, congestive heart failure.

RESPIRATORY: Occasionally has wheezing, but denies the diagnosis of emphysema, bronchitis.

GASTROINTESTINAL: Denies peptic ulcer disease, liver disease, hepatitis.

MUSCULOSKELETAL: Denies gout or arthritis.

UROGENITAL: Denies any kidney disease, kidney failure.

ENDOCRINE: Denies diabetes or thyroid disease. 

HEMATOLOGIC: Denies bleeding disorder, anemia.

IMMUNOLOGIC: Denies history of cancer, immunosuppression.

NEUROLOGIC: Denies stroke, TIAs or seizures.

PSYCHIATRIC: Denies depression or anxiety.

REVIEW OF SYSTEMS: 

CONSTITUTIONAL: Nausea and vomiting as above.  

SKIN: No rashes.  

HEENT: No hearing aid. 

RESPIRATORY: No asthma, TB, cough or shortness of breath. 

CARDIOVASCULAR: No MI or angina. 

GASTROINTESTINAL: No ulcers. 

GENITOURINARY: No stones or infections. 

NEUROLOGIC: History of stroke. 

PSYCHIATRIC: No depression. 

MUSCULOSKELETAL: Positive gout. 

ENDOCRINE: Positive diabetes.

HEMATOLOGIC:  No anemia.  On Plavix.

ALLERGIES: As above. 

REVIEW OF SYSTEMS:

The patient denies any fever or weight loss. Denies any blurry vision or diplopia. Denies any cough, rhinorrhea or sinusitis. The patient denies any chest pain, palpitations, dyspnea on exertion. Denies any shortness of breath, cough or wheeze. The patient denies any nausea or vomiting. Denies any hemetemesis. Denies any hematochezia. Denies any melena. Denies any urgency, frequency or dysuria. Notes vaginal bleeding as per the HPI. Notes no easy bruising or bleeding. The patient notes no rash or lesion. The patient notes no lightheadedness, loss of consciousness, loss of coordination, weakness or paresthesias. 

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever or weight loss.

HEENT: Denies visual changes, congestion, sore throat, sinus pain.

CARDIOVASCULAR: Reports chest pain associated with cough. Denies palpitations. Reports dyspnea on exertion and paroxysmal nocturnal dyspnea last night. Denies any edema or syncope.

RESPIRATORY: Reports shortness of breath and cough. Denies congestion, mild wheezing, no sputum production.

GASTROINTESTINAL: Denies any abdominal pain, hematemesis, melena, nausea, vomiting or reflux.

GENITOURINARY: She denies any dysuria or urgency.

MUSCULOSKELETAL: Denies any muscle or joint pain.

SKIN: Denies any rash or pruritus.

NEUROLOGIC: Denies any headaches, vertigo, weakness, numbness or tingling.

ENDOCRINE: Denies any polyuria or polydipsia.

HEMATOLOGIC: Denies any abnormal bleeding, bruising or lymphadenopathy. 

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever, chills.

HEENT: No bleeding, congestion, pain, discharge, epistaxis or rhinorrhea.

RESPIRATORY: No shortness of breath, cough, hemoptysis.

CARDIOVASCULAR: No chest pressure, tightness, heaviness, palpitations, syncope.

GASTROINTESTINAL: No nausea, vomiting, pain, melena, hematochezia, hematemesis, constipation, diarrhea.

GENITOURINARY: No dysuria, hematuria, change in color or smell or flank pain.

IMMUNOLOGICAL: No hives, itching, history of immune deficiency.

LYMPHATIC: No history of adenopathy, splenomegaly, splenectomy.

HEMATOLOGIC: No history of coagulopathy, thromboembolic disease, anticoagulant therapy.

NEUROLOGIC: Pain radiates down the right leg. Denies numbness, tingling. Denies ataxia. Denies trouble swallowing, slurred speech, blurry vision, diplopia, vertigo.

INTEGUMENTARY: Denies sweats, wounds, rash, bites, stings or IV drug abuse.

ENDOCRINOLOGICAL: No polyuria, polyphagia, polydipsia or temperature intolerance.

MUSCULOSKELETAL: As above. All other systems negative. 

 

 

 

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