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If you expand it (and you should if your account allows), sm

Posted By: nm on 2005-11-17
In Reply to: cardiac catheter - Lola

Subject: If you expand it (and you should if your account allows), sm

it should be "cardiac catheterization," not "cardiac catheter." 


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If verbatim then that is correct. If you have to expand (as in my account) it is maximum temperature
Subject: If verbatim then that is correct. If you have to expand (as in my account) it is maximum temperature. (nm)

x
Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
Subject: Depends on your account specifics. If they allow you to expand, that's fine, but it is straight

hardcore verbatim you have to leave it as is, whether it looks ugly or not.  I know, I really don't like it when they abbreviate left and right, leave words off sentence structures so they can speak faster and get it over with.



Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
Subject: Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm

not sure in this case.  Account goes by BOS, not super nitpicky, but I'm wondering what y'all do. 
account specifics for that particular account should state how it is to be typed. nm
Subject: account specifics for that particular account should state how it is to be typed. nm

.
Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100
Subject: Depends on the account: My verbatim account is VERBATIM and other accounts I put 3100


If that's what was said, yes. You'd expand the second one to 42,800 IF your QA allows it. If n
Subject: If that's what was said, yes. You'd expand the second one to 42,800 IF your QA allows it. If not,

s
if CP says to expand, I certainly do expand
Subject: if CP says to expand, I certainly do expand


Expand IV????
Subject: Expand IV????

How would I expand IV?  "Plan is to discontinue his IV."  When I look it up I get intravenous.  That does not sound right...... 


 


THANKS!!!


Expand LVH
Subject: Expand LVH

Not sure whether to expand LVH in assessment.  It does not appear expanded elsewhere in report.  Left ventricular hypertrophy or left ventricular hyperplasia??  Leave as is?
Unless you need to know it to expand it in
Subject: Unless you need to know it to expand it in

the report, I wouldn't waste time over it. If you need to know, ask your supervisor to find out for you.
how do you expand L5-S1 in a DS?
Subject: how do you expand L5-S1 in a DS?

How would you expand this sentence in the Diagnosis section of a Discharge Summary. 


Do I replace L5-S1 with lumbosacral joint? 


My account gives examples that we should expand "Fracture, L2" out to "Fracture, second lumbar" ....  so that is why I'm thinking I need to expand the L5-S1...


DIAGNOSES:


1.  Right-sided L5-S1 herniated nucleus pulposus.


 


I never expand
Subject: I never expand

Because abbreviations can mean so many things, I never expand abbreviations even in a diagnosis. Our hospital determined it is the dictators job to edit before signing if they want it expanded.
expand HPI?
Subject: expand HPI?

Forgive my newbiness (that WILL become a word someday, I'm sure of it!) that will clearly be seen in this question!

When the doctor dictates "as stated in the HPI" , should I expand that to History of Present Illness - with those caps in place or only capitalizing the H?

Thanks!
should expand
Subject: should expand

I'm told to expand all those that are not common. (How gloriously vague!) Seems to me that "HPI" is pretty common. But I think I'll go ahead and expand.

So should I capitalize all of it?
I would expand
Subject: I would expand

ANY abbreviations the client wants expanded. Everyone has a preference.
only expand it out to metastasis if.....sm
Subject: only expand it out to metastasis if.....sm

Client profile dictates whether or not to give this dictator mets or metastasis.....his saying *met* was wrong.  I would've given him *mets* unless the client profile allows expanding of words, and in that case I would've given them *metastasis*
I would expand all as you stated...
Subject: I would expand all as you stated...

I am not on a verbatim account and I do expand those types of abbreviations, but I would be interested in hearing others' opinions as well.

By the way, why are you "dubious"? Just curious!
I wouldn't expand it.
Subject: I wouldn't expand it.

Considering the context in which IV is used, it is its own entity.  I would leave it as is.
I think I would just expand this nonsense to have it be
Subject: I think I would just expand this nonsense to have it be

s
I always expand it to saturating. (nm)
Subject: I always expand it to saturating. (nm)

xx
How to expand UBJ obstruction
Subject: How to expand UBJ obstruction

Hi!  Need to type UBJ obstruction in an op note. Can't find anywhere in acronyms.  Anyone know?  Thanks in advance.
Unless you are to expand abbreviations
Subject: Unless you are to expand abbreviations

you transcribe it as dictated.
I always expand everything if CP says so, even lab tests..
Subject: I always expand everything if CP says so, even lab tests..

xx
Unless you have to expand all abbreviations
Subject: Unless you have to expand all abbreviations

don't waste your time worrying about it, just type it.
Expand BMI in op title? sm
Subject: Expand BMI in op title? sm

I couldn't resist putting Guess, since that's what I've had plenty of today.  Guess who dictated this report and put in ? maybe the wrong ID?  Or is it Dr. ??, or his/her (seriously, I can't tell) PA, or assistant... 


Okay, I had to gripe.  This is all I get lately.  I have actually broken my own record for finding someone who stutters more than someone I used to work for.  That's a terrible comparison, as everyone loved thiss doc and doc's dictation.


Thanks..


How do you expand DDAVP?
Subject: How do you expand DDAVP?

DDAVP is dictated in the assessment, in which no abbreviations are allowed. What is the expansion for DDAVP?
Guess I just won't expand it, still unsure....
Subject: Guess I just won't expand it, still unsure....

because too many times when he uses the term PFC there is no other indication of a joint replacement system having been done or anticipated, so I still have my doubts that that is really what he means by these initials.  Thanks for your help.
I won't type slang, never have, never will -- expand
Subject: I won't type slang, never have, never will -- expand


Should we expand things like MRI and CT in diagnosis? SM
Subject: Should we expand things like MRI and CT in diagnosis? SM

After getting some things back from QA, I am a little unsure on this. Thanks.


I expand it, as no abbv in Diagnosis
Subject: I expand it, as no abbv in Diagnosis

nm
Maybe "SK," but I'm not sure we have enough info to expand that. (sm)
Subject: Maybe "SK," but I'm not sure we have enough info to expand that. (sm)

I'm thinking they could be abbreviating a skin condition as "SK," but that could stand for a number of things (seborrheic keratosis [or keratoses], for one). Can't say....
I just expand to external fixator. I wonder if I'm wrong. nm
Subject: I just expand to external fixator. I wonder if I'm wrong. nm

x
I would expand it to saturating or saturations if allowed. nm
Subject: I would expand it to saturating or saturations if allowed. nm

s
I always expand stuff like that 'cause I'm a tool.
Subject: I always expand stuff like that 'cause I'm a tool.

Plus I like to get paid fer it...but mostly 'cause I'm an AAMT BOS tool ;-)       


    


Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
Subject: Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,

any ideas? 


Thanks


Unless specifically told to expand, leave as GI.
Subject: Unless specifically told to expand, leave as GI.

x
CBC with diff 4 *metas* -need to expand THANKSnm
Subject: CBC with diff 4 *metas* -need to expand THANKSnm

x
Probably saying "respiratory rate 20" and T-max would be correct or could expand to temperatur
Subject: Probably saying "respiratory rate 20" and T-max would be correct or could expand to temperature max.

x
So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Subject: So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma


oops, it's been a long day. Would you type "tox" or expand? nm
Subject: oops, it's been a long day. Would you type "tox" or expand? nm

nm
triple A=AAA, but I usual expand out to abdominal aortic aneurysm.
Subject: triple A=AAA, but I usual expand out to abdominal aortic aneurysm.

x
If not verbatim and you're sure of meaning, expand it and get paid for the characters. nm
Subject: If not verbatim and you're sure of meaning, expand it and get paid for the characters. nm

s
I expand CC to cubic centimeters or milliliters depending on which is correct.
Subject: I expand CC to cubic centimeters or milliliters depending on which is correct.

I always spell abbreviations out such as this one that follows a vague number , i.e., few, several, many, etc. It just doesn't look right having the abbreviation in that sort of sentence to me. If you adhere to the BOS, it suggests spelling them out in this instance as well.
account?
Subject: account?

NM
On the account I'm on they want us to
Subject: On the account I'm on they want us to

type out potassium chloride. Which I'm only too happy to do with a shortcut, LOL.


The account that I am on
Subject: The account that I am on

The account I type is "almost verbatim".  We type subcu, but in the lab values we have to expand the workds (alkaline phosphatase, et cetera).  If a word is dictated that is not a known abbreviation, we have to type it out.  I think each account is different, and as the other poster said, they should have given you an client form so that you would know what the hospital expects. Sounds like your guy kinda got his tail in a crack and felt like he needed to unload on a poor, innocent MT who was just trying to do her job!  Hang in there!      W'e're cheering for you!


 


g is okay per BOS, but I have an account
Subject: g is okay per BOS, but I have an account

where the client profile forbids it and it must be written out as grams. Maybe yours is account specific too.
I am on a new account and need some help here.
Subject: I am on a new account and need some help here.

Patient has a mild s/l list to the left.  This is orthopedic.  I have postural list in my Stedman's Ortho book.  Could that be it? 


New account for me/sm
Subject: New account for me/sm

All I know is baby had Norwood procedure on her heart.  Is it some sort of monitor?
Does your account use the BOS 2?
Subject: Does your account use the BOS 2?

That's the source of the "Don't capitalize it when it stands alone" rule. My suggestion would be to follow BOS if your account uses that and to be consistent. Stedman's is (are?) notorious for inconsistency with this sort of thing.
In verbatim account... HELP PLEASE

She is sating(satting) 98% on room air?


I want to change, but on verbatim, I suppose I'm not supposed to, right? I'm relatively new to this and not sure.