Hi! I was wondering if anyone could help me with this chart note. I am enrolled in the Medical Transcription Program through PCDI. It is an at-home course and I don't have great resources when I have a question or need help with some of the work. I have looked other places for a sample of a Neurology chart note but was unable to find one. I know without actually hearing the dictation, it may be hard to help me. But any advice, assistance with formatting, or pointing out of any errors would be greatly appreciated. Thank you. CHART NOTE This is a 22-year-old college senior who has has lightheadedness and dizzy spells going back a number of years but apparently, he never paid much attention to these spells until he had a seizure last year. He has so far had only one definite witnessed episode of grandmal seizure. He lost conscienousness and was witnessed to have jerking of the extremities. He did not have any tongue biting or incontinence. He has continued to have episodes of dizziness or lightheadedness and has been on Dilantin 100 mg orally t.i.d. since early July. On specific questioning, he recalls having had an episode while he was ushering at a light show. A blinking effect brought back memories of his seizure and he felt dizzy. He also recalls feeling somewhat nauseaed during these dizzy spells but denied having other symptoms of peculiar odor or taste during any of these episodes. He denies any other symptoms suggestive of jamais vu or deja vu and he denies any neurologic symptoms like head injury or episodes of vertigo, diplopia, frequent headaches, numbness, weakness, ataxia, etc. NEUROLOGICAL EXAM: Mental status seems entirely normal. Cranial nerves II through XII are intact. Sensory exam to light touch, pin ***** position, and vibration are completely normal and so are cortical sensations. Stereognosis is intact. Motor exam reveals normal tone and power. Deep tendon reflexes are bilaterally 2+. Plantars are downgoing. Finger-to nose, heel-to-shin, and tandem walking were well performed. Romberg's test was negative. IMPRESSION: This patient has a normal neurological exam. It sounds as if he had had at least one episode of generalized seizure and he continues to have episodes of dizziness or vagueness. He's already had a workup including a CT scan of the head with and without contrast, which was normal, an abnormal EEG with nonspecific slowing, and normal labwork including a normal DTT, CBC, SMAC, and urine catecholamines. If he continues to have definite seizures in spite of being on Dilantin, then he might be a candidate for a different anticonvulsant like Tegretol. Before making this change, I've rescheduled him for a sleep-deprived EEG with NP leads and will also obtain a Dilantin level. Depending on the results of those two studies, we will either plan on increasing his Dilantin dosage or changing him to Tegretol.

Hi Andrea, My name is Dawn White and i am a production coordinator for a medical transcription company located in Columbus Ohio. We are currently hiring for at home medical transcriptionist (yes even newbies). We do hire new grads because it is much easier to train. I would love to hear from you ( any friends also if they are interested) My contact email is [email protected]...... Please contact me so we can discuss you filling out our application, prescreen and taking our MT test. Thanks Dawn white

Hello! I just read your post and had to reply to you. I am just starting the process of working as a medical transcriptionist. I went to an interview yesterday and was told they would give me a chance even though I don't have as much experience as they'd like. The part of your post that struck me was that you said you were waiting for lap band surgery. I am also. I have been approved by my insurance company and now I have to have some testing done before a surgery date can be set. Where are you having your surgery? I am going to the Barix Clinic in PA. Jenny

Hi Mendy, I remember you from the Cali board. How u doing? This is my first time on this board. I am a medical transcriptionist, but out of work for a while, but not necessarily looking at this time.

I live outside the US , and I want to start my career as a Medical Transcriptionist . I have an excellent Medi9cal background, with resonable spelling & grammer capabilities. My question is : Should I live in The US to work as a Medical Trascriptionist ? Or, simply , I can receive and send the requested information via the web , working frm home , anywhere, worldwide. Please advise