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Spelling out abbreviations in the diagnosis

Posted By: see message on 2008-10-03
In Reply to: Sorry I even asked - frustrated

when told specifically not to is not following instructions.

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I am so sorry for your diagnosis...
I am reading your post with tears in my eyes. That so hit home with me. I don't want to have my kids growing up thinking our house is "normal" as messy as it is. God bless you and I will pray for you. I'm going to make some changes in my life today.
LOL!!! How about this diagnosis... sm

 And I quote - "History of injury of the poisoning at specified place."  I always have to correct this guy's grammar and tense, but what the heck do you do with something like this?!  I typed it as is and sent it on! 

Yes, I did go to the ER and my diagnosis was:

Complicated migraine.  And I am all better now.


Can I get some opinions before I make an appt with a doctor?  Have been having mild fleeting pains in my llq, probably about a week and a half, sometimes midabdomen, the last couple days it has slowly moved upward, now kind of in my chest but still just a mild dull ache - possibly pulled a muscle?  Don't think it is anything serious but is getting more prominent, any ideas?  Thanks.
So sorry about your diagnosis. sm
Why do you think she spread it around?  Concentrate on your diagnosis, treatment, and healing.
So sorry for your diagnosis..sm
you must be beside yourself. My sympathies!

as for the coworker, I can only comment that you had asked her to let you know, which she did. Perhaps she left off the part about the breast cancer because she did not want to be the one to tell you or let you know that. She wanted your doctor to do that. I really don't think she was doing anything wrong...other than maybe every body knows now. you know how that goes.

secondly, and I have said this before, transcription has HIPAA laws, which are a good thing, but because of a situation just like this one, I truly believe that if a Transcriptionist happens to know the patient involved, she should be able to respectfully decline to do that person's transcription. Just as in choosing a jury for a trial...if the prospective juror knows the person on trial, he should not have to be placed on that case. It would save an awful lot of this type of thing from happening, and everybody being *all up in your business*. Personally, if I received a dictation from someone I knew, I would not even want to do it. What is in those files is none of my business.

that is just my thought though.

I wish you all the best on your recovery. May the Lord hold your hand through it all!
Recent diagnosis of MS

Hang in there!  You can overcome a chronic illness and empower yourself.  It ain't easy, but doable.  Been that way for 12 years now.

Just make sure you file the disability with a disability attorney. SS is very well known for denying claims usually twice, then court before they grant it.  This waste many many months and tires us that are already tired, out.  You need all your energy to fight the disease, not for your rights to supplemental income you've paid for all these years. 

Your children will also receive dependent benefits until they reach 18, so again, get an experienced dis. atty.  Hang in there

Also, see what diagnosis code
they used to bill.  Might have been billed as a screening and that's sometimes a no-no as far as getting things paid.  Obviously, you can't lie, but see if she had any symptoms at all that might justify the test.  
sorry for your diagnosis..congratulate you on..sm
your wanting to raise your boys to be good housekeepers. I wish my husband's mother had taught him so many things..just simple little things about the house..like closing cabinet doors. No, truly I understand your thinking and even though I have not been diagnosed with cancer, I think about all the crap I've got stuck out in the shed that I need to get rid of so nobody else has to come along and get rid of all that crap for me. It's a lot to deal with for people who are grieving anyway.
Good luck and just said a prayer for you.
ADHD diagnosis
When our son was having trouble in school, we brought him to an expert in the field of ADHD, and after hours of testing he made the diagnosis, and, then after that got an IEP at the school. Every state is different in their different programs, but they all have to provide help for children with special needs. Our son was at a college at another state, they had his IEP and went there for two years, came back home and is at another local college and they told him he never should have had a full load of classes and he is given extra time for testing, etc. The school system should have a special needs department, like they do here in my state and you can contact them about extra help for autism, learning disabilities, etc. It makes a big difference in getting the kids all the help they need to succeed and not fail in any of the schools. Also, I believe the Americans with Disabilities web site can help also.
Very sorry to hear of your diagnosis...sm..

Like the other poster said, think positive and go forward from here with what you need to do. 

1.  You asked her to let you know if she typed the report so she did so that's not a violation.  It could be a violation if it wasn't emailed through an encrypted email program but I wouldn't make a stink out of that.

2.  She should know the rules and should know it's a major violation to blab to the department so if she has any brains in her head, she'll keep her piehole closed.  I wouldn't worry about it right now or jump to conclusions, but if you do later hear that others in the department know, I would report your suspicions to her supervisor. 

Are there any steps you can take at this point to keep it under lock and key so no one else finds can read your report in that department?

Beyond that, I wouldn't worry about it and would focus on licking this temporary setback.  I wouldn't worry about what's going through her head and why she isn't contacting you anymore.  She sounds flakey.  Focus on you and your family.

My sympathy as well on your diagnosis

But as a radiology MT you know that the treatment for breast cancer has advanced considerably and many women go on to live long, healthy lives after breast cancer treatment. So focus on the positive for the now.

As far as your coworker, I understand the desire to know the results of your tests, but yes, she should have told you to ask your doctor for the results instead of sending them to you.  Then, if she gave the results to anyone else, the HIPAA violation would be entirely on her part.  I don't know if you have spoken to her since she sent you the report, but it is possible that she was either caught sending the email or she talked to someone about it and was reprimanded for the HIPAA violation, therefore she is now afraid to talk to you at all because she does not want to risk getting fired. (Just one possible scenario.)

Your best course of action is just not to worry about the opinion of your coworkers. You have a job to do, and that is to concentrate on getting well.  Don't let this distract you.  Focus on what is important, and "don't sweat the small stuff".

Good luck!

Sorry to hear of your diagnosis
Unfortunately this happens when you have your tests done at the same facility where you are a patient.  I am also a product of feeling like "every knows".  It is not fair to you, but I feel in hindsight now I would never choose to go where I worked to have testing done unless I didn't mind that the people I worked with know of my personal health information.  It is a common thing in hospitals and physicians' offices for people to snoop and want to know your business and unfortunately, this isn't always a positive thing.  If you need other tests I would suggest trying another institution and also mention this to the physicians who care for you, but they may say the same thing - that you should NOT have asked a former coworker to let you know of your results.  Only the physicians have a right to that information and the right to relay that to you.  I fortunately did not have breast cancer, but my incident stemmed from having a mammogram.  My boss posed as a friend in the mammogram department the day I had the lumpectomy.  Yeah right, some "friend".  She was just being nosey and wanting to know when I would be returning to work because the typing was getting backed up.  Again in hindsight, I will never step foot in that hospital again for anything in regards to my health.  I go to a different hospital/radiology department from now on.    Good luck with your health and best wishes to a resolution to your anxiety.
proper diagnosis!!! for my exhusband too...LOL...sm
but it isn't really funny and I'm not really laughing.....it was him or my sanity, as I posted below, and my sanity won out but you have put the proper diagnosis on it because I've been saying for 20 years, he was/is a passive aggressive.....always pointing the finger, placing blame and never looking inside himself as maybe it's him who is/was the problem......(also a triple virgo male *LOL* sun, moon, rising-ascendant). 
Thanks to both of you...verbatim account. Has to be as dictated unless in diagnosis.

We do use dx for diagnosis, and all the short cuts expanders
I am on XANAX. I did not think my clinical diagnosis would be on report.
When given this diagnosis, the first thing you want to know is how far it has spread. It can mean life or death. My doctor was OOT for two more days and I was panicking. I needed to know if it was abnormal so I could begin thinking of what the future held. I am not thinking RATIONALLY!!!!!
Last week I've been diagnosis with Multiple sclerosis and I did sm
go to file my disability and found out what I would get paid if approve, I am working 7  days a week, 24 hours a day off and on.  My husband is deceased and I have two kids to raise and one must do what they have to do.
Diagnosis of perimenopause versus adrenal fatigue? I'm getting very confused on where to turn
To me, my symptoms coincide exactly what to me seems to be perimenopause, but also seem to be some adrenal fatigue as well. Wouldn't adrenal fatigue be a natural result of the perimenopause hormonal fluctations, i.e., very lethargic and listless, insomnia, mood swings, energy swings, fuzzy brain? I'm getting conflicting advice and opinions and just don't know where to turn anymore. I just want this fixed, and didn't think it should be that hard. I went to this GYN my sister referred, but he seemed to me to be rather clueless and had me do some antithyroid antibody tests and put me on fish oil and folic acid! No hormone testing whatsoever. Then, I talked to a pharmacist locally who also deals with women on this same issue (my sister too), who has a Ph.D and consults with the MD. I took her test and she diagnosed me with severe adrenal fatigue, but again, I think this is probably just a result of the hormones messing up. Any advice? I don't want to do a lot of unnecessary testing that insurance doesn't cover, such as the saliva test. I'd appreciate any advice. I'm thinking to just go maybe just go my my PCP and get on an antidepressant or something.
On anything that I want expanded and is also used as an abbreviation, I put an x at the end. Such as CHF, I have it as chf and will capitalize and then chfx will spell out congestive heart failure without a problem. I do this for all my abbreviations. Hope this helps.
I was thinking you could benefit from using a popular website for medical abbreviations. The sites are:
1) www.medilexicon.com
2) www.pharma-lexicon.com

You would enter the abbreviation and it will give you the definition. This is, of course, in addition, to your usual research methods using the search engine such as www.google.com

I do abbreviations like CHF is CHF and chff is congestive heart failure.  whatever it is I just double the last letter to get spelled out version.

abbreviations sm
I was taught years ago never to abbreviate in a diagnosis. I also would spell it out and put the abbreviation in parentheses as this is his direct dictation and that's how I've always done it. The BOS may disagree but never got called on it. I once wrote a physician a sticky note to please not dictate his diagnoses in abbreviations as they may be misinterpreted. He was nasty about it, but it is a very dangerous thing to do.
What is proper abbreviation for A Fib?
Thanks.  Thought it was a. fib. but saw it somewhere as A Fib and thought I was wrong. Looked in Stedman's Abbrev and it says AFib
I think it is best not to use abbreviations as much as possible.
In my opinion, I would prefer it typed "okay", but every company has their own opinion. If she is the boss, do it her way.
MM's abbreviations
You would have to add MM's expansions to Smartype yourself, one at a time. Here is a link for her abbreviations:


I use Barb Grow's vocabulary that I bought from her about 7 years ago. I don't have contact info for her now though, and I don't know if she still offers her vocabulary. I'd be lost without it. It makes much more sense than what the original Smartype or Stedmans came up with in their vocabularies. Her vocabulary is in the vcb format that goes into Smartype, ready to use.
abbreviations help

try this website: 


backing up abbreviations

I'd like to make a backup copy of all my abbreviations on Word Expander.  I use Bayscribe for my work.  Does anybody know how I can go about backing these up?  I'm concerned that all it would take would be a virus or something funky to happen to my PC, and I'd lose all those abbreviations.  I have stored over 2,000 my own abbreviations for a total of over 60,000 characters and would really regret all that work if something happened.  Thanks. 

backing up abbreviations
Thank you VERY much for the info!  Makes sense to me.  I'll give it a try. 
dangerous abbreviations
It really depends on the account. Some facilities/doctors really don't care for the new set of guidelines and want their work verbatim precisely. But employers want it practiced just in case for some of the more confusing abbreviations.
List of abbreviations
Yes, they are quite certain how wonderful that "dangerous abbreviations" list is, but don't kid yourself. There are quite a few physicians out there/facilities who don't care for the list and want abbreviations (and dictate them too) the former way; --- q.i.d., q.o.d., t.i.w., q. week, q. Monday, Wednesday, Friday, etc. Shall I go on? I know because I've transcribed from physicians dictating just this way. The docs want it THEIR WAY. Get over yourself.
need help on abbreviations board please...thanks
message abbreviations
What do sm and NM stand for? Is there a place to look up abbreviations used on this site?
I use the 1 after a lot of my abbreviations. How about cyto1? nm
Invalid abbreviations
Sorry, was reading quickly and missed where it was saying invalid abbreviations AND mixed Latin/English abbreviations. The actual paragraph reads:

Invalid Latin abbreviations such as q.a.m. (every morning) and mixed Latin and English abbreviations such as q.4 hours (every 4 hours) have become commonplace. However, as with all abbreviations, avoid those that are obscure (like a.c.b. for before breakfast) or dangerous. For example, b.i.w. is both obscure and dangerous. It is intended to mean twice weekly but it could be mistaken for twice daily, resulting in a dosage frequency seven times that intended. Copyright (c) 2002 American Association for Medical Transcription

Sorry for any confusion.
I think with the prohibited abbreviations
to spell them out is essentially typing vertabim- it is what the doctor said, you are not changing it. If a doctor is foolish enough to complain about that knowing the penalty for each incidence of a prohibited abbreviation then he needs to get his head out of his hind end.

I would check with your supervisor but surely when they say verbatim they mean not changing the sentence structure around or what have you. I can't imagine they would want you to type these abbreviations just because the doctor says it.
Medical Abbreviations
A really cool site for searching medical abbrevitions
Yes - it helped w/abbreviations, etc.
I think it helps to broaden your knowledge of certain standards if you're job hunting, even if you've never used them.  For example, you won't be surprised when you get a different job or client and someone chews you out about starting a sentence as "27-year-old patient comes in today" (versus "This 27-year-old..." or "Twenty-seven-year-old...").  JMHO and IME
I'd like to make a suggestion to MTStars.  There are so many abbreviations used on this web site and I often am unsure what they refer to.  I'd like to suggest that you create a board with the definitions of these abbreviations that we can refer to as we are reading.  I've been in this business for 18+ years and still many of the abbreviations are unfamiliar to me.  I am sometimes able to figure them out, but sometimes I'm just not sure.  I find your newsletter very interesting and helpful and a help tool like this would only add to it.  Thanks for taking the time to consider this.
Dangerous Abbreviations

Q.D., QD, q.d., qd (daily) = Mistaken for each other = Write "daily".

I woud say this should over ride anything BOS has to say, but we aim to please the client.  As transcriptionists though we should be aware of these dangerous abbreviations since it can affect a patient's medical record and how it is interpreted.

Abbreviations Book
Can someone recommend a good abbreviations book or a good website to use as a resource? I have Stedman's Abbreviations and I am not that happy with it. Thanks in advance!
Dangerous Abbreviations
"IV" isn't on the Joint Commission list of dangerous abbreviations. Don't take this as an indication that you're getting old--the confusion surrounding those darned abbreviations can be aggravating.

Here are some reasons for the aggravation. You might have seen it on a facility's list in the past or you might have encountered it as a recommendation from a consultant or in a journal article. Before The Joint Commission solidified its list of dangerous abbreviations, there was a lot of confusion about this--some groups banned any and all abbreviations.

There is an abbreviation that is banned because it can be CONFUSED WITH "IV." It's "IU," the abbreviation for "international unit." While it's OK to use IV, some facilities do not want you to use it, reasoning that if IU can be confused with IV, then IV can be confused with IU. And then some would want you to avoid using IV, until they discover that they have to pay extra for you to transcribe "intravenously."

Here is a link to the whole list. The document on The Joint Commission website was broken, so this link is to another website, but it is the same thing. http://www.aapmr.org/hpl/pracguide/jcahosymbols.htm

How would they know what abbreviations you used. (No message)
She does mention the abbreviations in
Thoughts on dangerous abbreviations

You're partly right.  Joint Commission has no jurisdiction over a private office setting; however, this was adopted by Joint after it was first given to the national pharmacy assocition.  When a doctor has his/her nurse phone in a prescription or writes one himself regardless of private office or inpatient setting, s/he better follow these guidelines. 

Having worked in a pharmacy, I understand how critical it is to be able to know EXACTLY what the doctor wants the patient to have presribed.  Pharmacy is going down the same path as MT work.  Notice how many insurers allow for your prescriptions to go to a mail order company who will fill up to three months of your prescriptions at a time.  The first line of defense these companies have (well, really just one anymore as they are becoming the MQ of pharmacies), is to scan the prescription.  If it is not written clearly, a body must contact that physician.  Addtionally these mail order companies allow MDs to relay prescriptions online.  These guidelines better be followed or they will be contacted.

Depending on which division within the mail order pharmacy you work, a tech may fill more than 100 prescriptions an hour.  If ONE of those prescriptions is filled incorrectly, it is reported to the State Board of Pharmacy who requires a monetary penalty be forwarded by the company depending on the error classification.  If there are too many errors in a given month, the pharmacy is shut down, the supervising PHARMACIST receives (typically) a $5000 fine and a one month to five year suspension of practice, all actions of which are published and distributed to all 50 states in a monthly newsletter.

To say this is all AAMT's fault is ludicrous.  To say the doctors are not going to change their ways because they have god complexes is ludicrous.  This happened because too many mistakes were being made through haste, bad handwriting, lack of time to thoughtfully write prescriptions, etc.  This is today's reality.  If you do not adapt, you do not survive.  Just ask a Cro-Magnon.


Grrr! I just had a doc who spelled the abbreviations!

COPD, that's captial C, capital O, capital P, captial D.  LAD, capital L, capital A, capital D. 


Patient has been in drug recovery - that's R-E-C-O-V-E-R-Y

Really?  I did not know that.  Thanks so much. 



I use Stedman's Abbreviations, Acronyms, and
Symbols. Works nicely. I also go to www.medilexicon.com quite often. Using that website prevents me from having to stop and look it up in the book.
Are these abbreviations taken? I'm seriously considering starting my OWN association sm

and calling it AMTS: AMERICAN Medical Transcription Society and leave the AAMT or whatever their new name is, to the transcription WORLD.


My "society" would be kind of like them but the only difference is that absolutely NO oversea members would be allowed; only those American MTs working in other countries who could prove to the society or association that they are, in fact, American Born and Bred.

What do you say? I would charge a minimal amount per year and begin local chapters.....by contacting local colleges and tech schools and employers telling them about our local networking, American, society or association.

I would periodically work with large MT companies and large hospitals telling them of our highly skilled MTs and DEMANDING that pay be increased and showing them why American MTs are the way to go......Doesn't that sound like fun?  It wouldn't be anything like a union, as I don't believe in unions, but a UNION of MTs around this great country I call MY AMERICA!


GOD BLESS AMERICA AND GOD BLESS YOU!!!!! Allah and Buddha could bless the AAMT all they want, but I just don't think they will do that.