I believe that "q" is a prohibited abbreviation per JCAHO. I usually put "a day" or 

• Question on Abbreviation - Chris
  • I use "daily." - NM
  • I believe that "q" is a prohibited abbreviation per JCAHO. I usually put "a day" or  - RockinMT

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I am typing a report that requires diagnosis abbreviations be expanded.  In all my years working I have never expaned "ST" could use some guidance.

The diagnosis is  ST elevated myocaridal infarction. 

TO my knowledge I have always thought it to be S-wave and T-wave?  any advice.

Calculated cardiac index was 1.9 meters per minute per meter squared.

1.9 m/min/MSQ ???

Or just write it out?  TIA!

TOT = total?  Does TOT stand fo something else too? 

Thank you. 

Does anyone know if b.i.d. and q.d. have been acceptably changed to BID and qday? I have a doc making abbreviations for everything ( I think to save money), but these are 2 that I am not aware of...thanks!

Doc dictates he has no previous hx of PTV.  Does anyone know what PTV stands for?

What is the abbreviation for milliamp?  (sp)

TIA

Tina

She is saying "TGA" for a diagnosis.  Patient with memory loss episode.

I thought she meant TIA which fits the patient's symptoms but she says it a few times in the report.  What is TGA ??    I'm stumped.

Listed as a discharge diagnosis and sounds like "history of WDA" or "WTA."

Patient has an IV drug abuse history, bipolar, hep C positive, and acute renal failure.

Thanks! 

Anyone know what PUND stands for, or am I misunderstanding the letters?  It is in a Narrative report for L&D.  She says, Diagnosis:  PUND with painful contractions....

Some contusions, secondary to his s/l mba, nba ?

Doc dictates "b.d" instead of b.i.d.  Has anyone heard of this?  I'm not sure what to transcribe.

Thanks

MD dictates, "there was a second-degree MLL repair with 3-0 Vicryl."

In 20 years, I've never heard this, anyone know what MLL stands for?  Maybe it's just the resident making up her own shorthand????  Help!

This is under the Eyes heading.  It sounds like the doctor is saying "PRL UMI".  I cannot find anything on this.  Any help is appreciated.  Thanks in advance!

POSTOP DX:  Nonviable ostomy status post APR, status post revision of ostomy.

Is this a legal abbreviation in an OR report?  Where can I find rules on what is and is not acceptable in each type of report, i.e. H&P, PN, OR, DS, etc.

TIA

When a doctor refers to the cervical spine in a report as a c-spine, should it be expanded or should it be left alone (not in diagnosis), and should the "c" be capitalized or lowercase?  I have researched and I am seeing it both ways.

Also, does a physician place a patient "on a cervical collar" or "in a cervical collar"? Physician states "on" which makes sense, like they are placing them on a medication, but it just looks weird.

Hi... Can someone tell me the correct format for what comes after this med in a dictation:  "Zarontin 250 mg 500 500 250 500?"  Is this 500 am, 500 mid-am, 250 afternoon, 500 bedtime?

Thanks! 

When in doubt, I refer to Stedman's Abbreviation book.  For example, I have always hated typing "afib" for atrial fibrillation, so I looked it up.  In this book, the proper way to abbreviate it is AFib.  As far as cc versus mL, that is a Joint Commission requirement, not a BOS issue.  Another example is sed rate.  There is no approved abbreviation that sounds like sed rate, but the book shows sed rt, which is something I wouldn't use.  Sed is truncated, not abbreviated, so I expand to sedimentation rate.

I work for 2 companies with slightly different approaches to a couple of BOS issues, both being very reputable MTSOs, so I have to keep them straight in my head.  One wants me to use platelets if that is what is said in the CBC dictation; the other wants me to use platelet count.

You will have to decide what path you need to take.

Patient is being admitted to the s/l SIB, SIP, FIB, FIP service.

(patient with chest pain in the ER).