Abbreviation Format
Posted By: emtrans on 2006-08-29
In Reply to: I personally would just separate - ....
Subject: Abbreviation Format
Thanks! I thought that would be a mega-dose as well, but that's what she said. I did "slash" them though.
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Abbreviation Format
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!
As q. day is a dangerous abbreviation, the correct format is p.o. daily...:)...nm
Subject: As q. day is a dangerous abbreviation, the correct format is p.o. daily...:)...nm
x
format
Subject: format
No.1 PDS or #1 PDS? Which is correct?
Format ?
Subject: Format ?
5/5 strength throughout sensation is intact. So the 5/5 is not at the start of the sentence, how would you reword this phrase?
OB format for G 3, P 1-1-0-2
Subject: OB format for G 3, P 1-1-0-2
Is this how you type that? I havn't heard it transcribed that way before... Thanks!
Format Help
Subject: Format Help
How do you type the name of a book? Italics or quotations? TIA
Format help
Subject: Format help
I have a dictator who constantly repeats words, phrases, entire sentences! Do you transcribe it twice or if she has already stated it, leave it out?
Format ?
Subject: Format ?
Would it be MEDICATIONS: Include
1.
2.
3.
H & P Format
Subject: H & P Format
Just when I think I have it on format - I don't. The following is under PHYSICAL EXAMINATION. What would the subheading be?
Patient walks to the right occasionally. She has trouble getting started because of discomfort. She can walk on heels and toes briefly. However, on a tandem walk she really has difficulty with that. She does not line up her toes easily, loses her balance very easily with that. This is typed as dr. dictated. Suggestions would be appreciated.
format question
Subject: format question
Do you put immunizations under the Social History section in a report or by themselves? I'm not testing, just confused. The doctor is dictating: "All immunizations are up to date" under Social History. Thanks.
Format question...
Subject: Format question...
Hi, I'm wondering whether AAMT BOS says to type this: "image #31 series 3" or this: "image #31, series 3." Comma or no?
Thank you! :D
Format question
Subject: Format question
This is so small I hate to ask, but everytime I type this it just looks odd no matter what way I type it and would like to know how another MT would type this.
If someone has a dull aching sensation or sharp stabbing sensation would you hiphenate (dull-aching sensation) or slash (dull/aching sensation) or just leave it (dull aching sensation)? Thanks for any input to my "stupid" question.
I would say cecal and S1-S2 is how I format it...nm
Subject: I would say cecal and S1-S2 is how I format it...nm
s
number format
Subject: number format
When transcribing a very large number, "1 million 120 thousand" is it considered more acceptable to use words or just to stick to numbers?
Format question
Subject: Format question
I was hoping someone might be able to give me the rule for this.....Should departments be capitalized? For instance, "she saw University of Virginia orthopedics" Should orthopedics be capitalized or not? I'm always confused about this:)
format question
Subject: format question
I was taught that if the "orthopedics" came after the name of the place, it should be capitalized (UoV Orthopedics). If not, it wouldn't be capitalized(orthopedic department at UoV). Please correct me if I'm wrong, anyone! :)
Punct? format?
Subject: Punct? format?
REVIEW OF SYSTEMS
He is 6 feet tall and weighs 260 pounds. His weight has been stable. No rashes. No problems with his eyes, ears, nose or mouth. Respiratory: he is positive for a smoker, half pack per day, with a smokers cough. Cardiovascular: has a history of hypertension. No GI/GU problems. Musculoskeletal is stated in the HPI. No neurological or hematological disorders.
Is this how this should be put in paragraph form with the Respiratory and Cardiovascular??
Radiology Format ??
Subject: Radiology Format ??
DUPLEX SCAN OF LEGS
Duplex scan of the arterioles system in the legs was performed and results are as follows:
RIGHT LEG: On the right side,
Is this layout correct? or is it
RIGHT LEG no colon? then drop down a line? Thanks
Format rules in MT
Okay, I am an old gal working mostly ias in-hospital MT (VA, Teaching hospital), but I did also work off and on for MTSOs at home. Now going back a long time, I was always taught that in formatting Problem Lists or Hospital Course by problem list you transcribe it this way. Problem #1 - HYPERTENSION. The patient is taking lisinopril currently..... or if the doc did not say PROBLEM #1, then you transcribed it 1. HYPERTENSION. Blah, blah, blah. When did this change and become wrong? Most of the docs I am now transcribing for one of the major MTSOs now (left the hospital), actually ask that we capitalize the major problem. Is this in the so-called AHDI BOS2?
IMHO, using the capitalization on the problem is much easier to read, than this...
1. Hypertension. The blah, blah, blah..
2. Diabetes mellitus type 2. Uncontrolled. Not compliant.
Any QAers out there can answer this one for this old school nitpicker?
format that to your accts specs (sm)
Subject: format that to your accts specs (sm)
a.m., AM, whatever your acct likes! LOL
Format for multiple problems
Subject: Format for multiple problems
Can someone show me an example of how to type a report that has multiple problems. The doctor does one problem completely, then goes onto the next one.
It doesn't look right typing HISTORY OF PRESENT ILLNESS, PHYSICAL EXAMINATION twice throughout the report.
Thanks
Format & Capitalization (psychiatric)
Subject: Format & Capitalization (psychiatric)
Capitalize verbal, performance, and full-scale? Should I leave the subtest scores in a vertical list arrangement or use a different format?
On this administration of the Wechsler Adult Intelligence Scale-III, Mr. ___ obtained a verbal IQ of 57 (range 53-63), a performance IQ of 64 (range 59-73), and a full-scale IQ of 56 (range 53-61). These scores fall within the mild range of mental deficiency.
The following scatter of subtest scores was obtained: VERBAL: Vocabulary: 2 Similarity: 3 Arithmetic: 2 Digit Span: 3 Information: 3 Comprehension: 2
PERFORMANCE: Picture Completion: 4 Digit Symbol: 4 Block Design: 4 Matrix Reasoning: 5 Picture Arrangement: 4
All the scores above fall within the mentally deficient range and are relatively even.
Go to format/paragraph and you'll see it. nm
Subject: Go to format/paragraph and you'll see it. nm
In MSWord, go to Format, Font,..
Subject: In MSWord, go to Format, Font,..
Effects, place a check mark next to Subscript.
Just a general question on format
Subject: Just a general question on format
I have been using these forums for a while now and I keep seeing people using "nm" and "sm". What does this mean?
nm = no message
sm = see message
Just a guess
Time format in BOS 3rd edition
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever.
I do intend to buy my own soon but I have to wait till payday. :(
Much appreciated !
Format/Grammar/Punctuation Help (psychiatric)
Subject: Format/Grammar/Punctuation Help (psychiatric)
DIAGNOSTIC ASSESSMENT: AXIS I: Psychosis NOS, schizoaffective disorder, bipolar type versus bipolar I disorder versus a drug induced psychosis, also polysubstance abuse. Should the word versus be transcribed as a slash or another format in this example? Thanks!
Medquist letter format question...
Subject: Medquist letter format question...
I never usually have to type letters so I am unsure of the format. Are we supposed to type the "Sincerely," and are we supposed to indent it?
Thanks!
He dictates in SOAP format so that might look out of place.
Subject: He dictates in SOAP format so that might look out of place.
Time format rules in BOS 3rd edition?
Can anyone tell me what the specific rules are for time format in the new BOS on pages 337-339. A brief description would be great or u can scan and email it to me too, whichever is easier.
I do intend to buy my own soon but I have to wait till payday and I'm starting a new company right now that uses that book :(
TIA !
Axis format but employer prevails
Subject: Axis format but employer prevails
I go like so
Axis I
xxxxx
xxxxx
xxxxx
Axis II
Axis III
Axis IV
Axis V
3 months' time is the correct format
Subject: 3 months' time is the correct format
SOAP is a really archiac format, rarely used today
Subject: SOAP is a really archiac format, rarely used today
and occasionally used today but rare.....
abbreviation help
Subject: abbreviation help
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.
Abbreviation CO2
Subject: Abbreviation CO2
Do we expand this? Someone was telling me that we are supposed to not use the abbreviation but I am having a hard time documenting this.
another abbreviation that might fit is CTS
Subject: another abbreviation that might fit is CTS
Abbreviation help please....
Subject: Abbreviation help please....
Calculated cardiac index was 1.9 meters per minute per meter squared.
1.9 m/min/MSQ ???
Or just write it out? TIA!
Abbreviation help
Subject: Abbreviation help
If the doctor starts a sentence with an abbreviation, is it o.k. to use the abbreviation to start the sentence? thanks
Abbreviation TOT
Subject: Abbreviation TOT
TOT = total? Does TOT stand fo something else too?
Thank you.
ABBREVIATION HELP
Subject: ABBREVIATION HELP
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!
abbreviation
Subject: abbreviation
Doc dictates he has no previous hx of PTV. Does anyone know what PTV stands for?
abbreviation
Subject: abbreviation
What is the abbreviation for milliamp? (sp)
TIA
Tina
abbreviation help - TGA
Subject: abbreviation help - TGA
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.
Abbreviation WDA/WTA??? sm
Subject: Abbreviation WDA/WTA??? sm
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!
Abbreviation
Subject: Abbreviation
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....
Abbreviation
Subject: Abbreviation
Patient was scheduled for epidural steroid injection but left the SPU or FPU without having the procedure due to anxiety.
Abbreviation
Subject: Abbreviation
Ok, patient had TNA as a child. Cannot find TNA meaning.
abbreviation
Subject: abbreviation
Some contusions, secondary to his s/l mba, nba ?
abbreviation help
Subject: abbreviation help
ESI - epidural steroid injection???????
ID abbreviation
Subject: ID abbreviation
Hi, all. When you abbreviate ID for Infectious Diseases, do you type it as ID or I.D.? Thanks! Happy early New Year!
re: abbreviation
Subject: re: abbreviation
Typing verbatim if allowed is best as it takes the liability off of your shoulders and places it on the doctor's shoulders if there is ever a doubt.
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