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In the diagnosis, I would (no abbreviations)

Posted By: MTISME on 2008-09-09
In Reply to: Tib-fib fracture - Bilbo

Subject: In the diagnosis, I would (no abbreviations)




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These are probably not abbreviations. sm
Subject: These are probably not abbreviations. sm

Is that the entire EKG interpretation? Check your BOS for help with EKG terms.
CT KUB/Abbreviations
Subject: CT KUB/Abbreviations

Check a TT SF CB DD CC....I wish they would just drop the abbreviations. All the "e" letters come across sounding alike as do the S's and F's. Then there are the B's and V's. There are about 35 abbreviations for CT,the most common of which is computerized tomography, but the list goes on and on. Cobra toxin is a good one!
Abbreviations.
Subject: Abbreviations.

2-3-day history of a pelvic pain along her bladder area. This pain is described as a constant crampy pressure pain, tender to touch, and is associated with urinary urgency and frequency. She denies any S/C/N/V/D/C.


New doctor for me. She likes to use a lot of abbreviations. Not sure what S/C/N/V/D/C is.


Also, doctor uses "MRC CUA" under plan. It is just by itself. Any clues?????


Abbreviations (sorry not much help)
Subject: Abbreviations (sorry not much help)

According to Stedman's  BSA= body surface area.  BFA abbreviations do not make sense here (BFA= baby for adoption  or  bifemoral arteriogram.)  Hope this helped a little anyway! 
abbreviations...
Subject: abbreviations...

Don't you just love them: Let's see there is:
1. continuous performance test,
2. continuous primary tests,
3. chest physiotherapy,
4. clinical pharmacokinetics team,
hmmm, I wonder, which one sounds the best to you?
There are many abbreviations that have
Subject: There are many abbreviations that have

more than one meaning, if in doubt use the abbreviation, EVEN if it is in the diagnosis.
abbreviations AS, AI, MR??
Subject: abbreviations AS, AI, MR??

I have to expand these abbrevations, but I'm having a hard time finding which ones are the right ones. The sentence is "multiple murmurs of AS, AI, and MR"
Stedman's Abbreviations has it as
Subject: Stedman's Abbreviations has it as

T-MAX, Tmax, or T-max. but don't take my word for it. Ask the others on this site who know everything.
also in Stedmans abbreviations nm
Subject: also in Stedmans abbreviations nm


What abbreviations are and are not appropriate will be different for each account sm
Subject: What abbreviations are and are not appropriate will be different for each account sm

Go with what your QA tells you.  It may be acceptable but the doctor may not like/want it done that way.  I've found every account has different rules and preferences.
metric abbreviations- sm
Subject: metric abbreviations- sm

Is one form correct over another when abbreviating the measurement 'microgram?'  I know I've seen it abbreviated as mcg, but in my chemistry background, we always used the symbol that looks like a funny letter 'u.'  I can type that symbol in Word, but I'm not sure if it's necessary or preferred.  This is the first time I've had the term 'microgram' dictated. 


Side note, do you use upper or lower case 'L' to represent a liter?  I've seen both used. 


Unless you are to expand abbreviations
Subject: Unless you are to expand abbreviations

you transcribe it as dictated.
According to the Stedman's abbreviations
Subject: According to the Stedman's abbreviations

& Acronyms it is

geriatric assessment unit
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.
no, This dictator is big on abbreviations, but I just can't get it, nm
Subject: no, This dictator is big on abbreviations, but I just can't get it, nm

x
Expanding abbreviations
Subject: Expanding abbreviations

Are there any abbreviations that should NEVER be expanded on the diagnoses section of a hospital record?  I was told that T-spine should never be expanded to thoracic spine; however I learned that ALL abbreviations are to be expanded and dont agree.  Please help. 
even though I, too, avoid using abbreviations in dx, I
Subject: even though I, too, avoid using abbreviations in dx, I

would have used the "B" - mainly because you just don't often see the term "beta" strep used - you always see "group B strep," so I think that's why they changed it.


dangerous abbreviations
Subject: dangerous abbreviations

Now please do not flame me for asking, but I am getting confused about some of these.  The one for today is hs.  Is it used at all?  If so, is it hs or h.s.?  I thought it was not used, but substitute "bedtime", but I do not find it in BOS and on page 463 of BOS 2 it lists "BT" as to not use but substitute "hs."  Can anyone give me a definitive reply with citation of source?  Thanks.
lung exam abbreviations
Subject: lung exam abbreviations

On lung exam is sound like he is saying "BS equals BO" or "PS equals PO."  Anyone have any idea?
I checked my Stedman's Abbreviations
Subject: I checked my Stedman's Abbreviations

book on this and it was not in there (surprise!) but I put the abbreviations into google and it came right up. Maybe I had better get a newer book. lol
But cc is on the dangerous abbreviations list
Subject: But cc is on the dangerous abbreviations list

Most places want you to change to mL (or sometimes even milliliters).



Discharge Summary Abbreviations
Subject: Discharge Summary Abbreviations

Must we expand all abbreviations in the Discharge Summary (as you would in a diagnosis/impression), or type verbatim?
Stedman's 3rd abbreviations has it both ways.
Subject: Stedman's 3rd abbreviations has it both ways.

nm
"Metastases" according to Stedman's Abbreviations
Subject: "Metastases" according to Stedman's Abbreviations


Page 8 under Abbreviations in BOS II, says to keep the periods
Subject: Page 8 under Abbreviations in BOS II, says to keep the periods

s
With the dots as in b.i.d. but q.d. is now on Dangerous Abbreviations
Subject: With the dots as in b.i.d. but q.d. is now on Dangerous Abbreviations

s
Breakdown of ABG: Correct abbreviations? sm
Subject: Breakdown of ABG: Correct abbreviations? sm

When transcribing results of arterial blood gas tests, which abbreviation is correct:  PAO2 or PaO2?  Each of these has different meanings, according to the website I use for acronyms/abbreviations.  Actually, I have always typed PAO2, don't know if this is correct, and have never heard otherwise.


Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM

ss
This is how my medical abbreviations book has it
Subject: This is how my medical abbreviations book has it

z
Good site to look up abbreviations -
Subject: Good site to look up abbreviations -

http://mt911.com/site/search/abbreviation_search.asp
Would "MRI'd" be incorrect? Dr. wants to use abbreviations for this too. n/m

n/m


I couldn't find anything...but sometimes I check here for abbreviations that I don't get..sm
Subject: I couldn't find anything...but sometimes I check here for abbreviations that I don't get..sm

http://www.medilexicon.com
Abbreviations per book of style question - sm

Do you abbreviate mg, ml, 02 etc if the account instructions say to spell out abbreviations as per book of style? 


 


Have ordered book, not here yet.  Thanks in advance for help.


Rehab note. He is using a lot of abbreviations. I am not able to document what they mean. *sm*
Subject: Rehab note. He is using a lot of abbreviations. I am not able to document what they mean. *sm*

Please let me  know if I have anything wrong.  Thank you so very much!


MODALITIES:  Transfers are minimum assist.  Balance trunk is  
fair to poor.  Endurance fair to poor.  PT goals are maximum  
assist with TIF.  Maximum assist with bed mobilities.  Progress
toward weeks goals PT is EMO at times of HOA.      


 


           


Clarification - Hopital Course - leave abbreviations?
Subject: Clarification - Hopital Course - leave abbreviations?

Oops!  I meant, in the discharge summary under the hospital course heading must we expand dictated abbreviations as we would under the impression or diagnosis?  Or is it acceptable to leave them verbatim.


Thanks!!!!!!


No, it stands for brain according to Medical Abbreviations 9th Edition and the
Subject: No, it stands for brain according to Medical Abbreviations 9th Edition and the

Laboratory Test Handbook, 2nd Edition.
Need good site for professional abbreviations such as NPCDE, etc nm
nm
This is from medilexicon list of abbreviations, I do not know if any fit in your context... and weir
Subject: This is from medilexicon list of abbreviations, I do not know if any fit in your context... and weirdly enough it says also electroconvulsive therapy, don't know why?

ETC
1-Ethyl-3-[3-(Trimethylammonio)Propyl]Carbodiimide Dict | PubMed | Wiki
Electroconvulsive Therapy Dict | PubMed | Wiki
Electron Transport Chain Dict | PubMed | Wiki
End Point Threshold Concentrations Dict | PubMed | Wiki
Esophageal Tracheal Combitude Dict | PubMed | Wiki
Estimated Time of Conception Dict | PubMed | Wiki
Extracellular Toxic Complex

Per Stedman's Abbreviations - PAR-Q is Physical Activity Readiness Questionnaire...nm
Subject: Per Stedman's Abbreviations - PAR-Q is Physical Activity Readiness Questionnaire...nm


You'll have to search for the dangerous abbreviations list to see, but ultimately
Subject: You'll have to search for the dangerous abbreviations list to see, but ultimately

s
AAMT BOS2 states that diagnostic abbreviations are acceptable in diagnoses
Subject: AAMT BOS2 states that diagnostic abbreviations are acceptable in diagnoses


Per Sloane Medical Abbreviations and Eponyms it has it as Adult and so does http://www.jdmd.com/glos
Subject: Per Sloane Medical Abbreviations and Eponyms it has it as Adult and so does http://www.jdmd.com/glossary/abbreviations-ae.html


External/internal range of motion with tibiotarsal pain (TTP?) docs can make up abbreviations, ???n
Subject: External/internal range of motion with tibiotarsal pain (TTP?) docs can make up abbreviations, ???nm

nm
Diagnosis
Subject: Diagnosis

Diagnosis:


1. Corneoscleral laceration with lens rupture O.D. and intraocular foreign body O.D. status post vitrectomy, lentectomy and uveal excision.


Should that be two sentences? I always have a problem with status post. Thank you so much.


Diagnosis?
Subject: Diagnosis?


Do you have a diagnosis?
Subject: Do you have a diagnosis?

nm
Help with diagnosis
Subject: Help with diagnosis

Chronic swelling of the right lower extremity after partial (frustray or first rate) resection for osteomyelitis.


It would be diagnosis, because SM
Subject: It would be diagnosis, because SM

Axis I, Axis II, etc. are arms of the diagnosis. 
diagnosis? nm
Subject: diagnosis? nm


this is the diagnosis
Subject: this is the diagnosis

1.Acute gastric tract.
2.Dehydration.
3.Urinary tract infection.
4.She was in motor vehicle accident.
5.Mental retardation.

It was diagnosis so just the
Subject: It was diagnosis so just the

sounded like posse vasculitis. Thanks