And where did the AAMT
Posted By: mtanon on 2006-10-24
In Reply to: Not anymore...according to AAMT now always use disk, for eyes too. nm - nm
Subject: And where did the AAMT
get this information?
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may I just add something about AAMT...sm
Subject: may I just add something about AAMT...sm
While I used to respect the AAMT, the AAMT is not the end-all, be-all, and, in fact, prior to the late 1990s, their book was 80 pages long....
just my 2 cents....
According to AAMT and ..
Subject: According to AAMT and ..
the Pharmicist's association, q.d. is on the "dangerous abbreviations" list. So if you did shorten it to the abbreviation, it can only be "1 daily" or "1 every day"
AAMT
Subject: AAMT
In my most humble opinion, I would think the AAMT BOS rules are set by AAMT, as Joint Commision accredits hospitals. Some of the style guides that my account uses are actually requirements by Joint Commission, but not those specifically required by the BOS. Anyone else have an opinion? 
I mean q.6h. (per AAMT)
Subject: I mean q.6h. (per AAMT)
nm
AAMT BOS
Subject: AAMT BOS
"I wrote him a prescription for 38 Tylox." Am I supposed to type #38 or not? 
Per AAMT
Subject: Per AAMT
Abbreviate units of measure, even if dictated in full, if they are accompanied by a numeral.
I would assume in your case since it is not accompanied by a number and has the word of between the two, then I would spell it out.
# according to AAMT
Subject: # according to AAMT
I type for a hospital so # are not written out. I only have the first AAMT book. In the new book, is it now standard to not write out #. I am QAing a clinic where they told me to use my own judgement as half MT are writing them out and the other half are not. What is new standard rule?
AAMT BOS
Subject: AAMT BOS
Use only with numerals. Use a lowercase x in expressions of area and volume, as a multiplication symbol, and when it takes the place of the word times.
A capital X is generally used to express magnification.
X30 magnification
x meaning by (dimensions)
Use a lowercase x to express by in dimensions.
Space before and after the x.
13 x 2 cm
x meaning for
When the word "times" is dictated and can be translated as for, it should be transcribed as for rather than using times or x.
D: The patient was given antibiotics to take times 2 weeks.
T: The patient was given antibiotics to take for 2 weeks.
x meaning times
When the word "times" is dictated and means the number of times a thing was done, the letter x can be used.
To keep this expression together and easily read as a unit, do not place a space after the x.
D: Blood cultures were negative times 3.
T: Blood cultures were negative x3.
Use the symbol x meaning times only when the x precedes a numeral.
D: Demerol was administered 3 times.
T: Demerol was administered 3 times. not ...3x.
Yes, BOS is from AAMT, but
Subject: Yes, BOS is from AAMT, but
what they base their decisions on I'll never know.
A new BOS is being written, and the new writers have some much better credentials than the former writers, so hopefully the new one will make actual sense. One can only hope.
it is CT per AAMT
Subject: it is CT per AAMT
x
AAMT BOS
Subject: AAMT BOS
affect, effect
These terms often sound alike when dictated, but their usage and meanings are not interchangeable. Affect is usually a verb, and effect is usually a noun. In medicine either of these terms may be a verb or noun, with a multitude of meanings, and their differences in usage and meaning should be learned.
affect
As a verb, affect (pronounced af-féct) means to influence or change.
She suffers from a neuropathy affecting her upper extremities.
The warm encouragement of the patient's wife positively affected his outcome.
As a noun, affect (pronounced áf-fect) means an expressed or observed emotion or feeling.
The patient displayed a flat affect.
Her affect did not change throughout the course of the interview.
effect
As a verb, effect means to bring about or cause to happen.
We plan to effect a decrease in the size of the tumor using adjunctive therapy.
The medication effected relief.
As a noun, effect means result.
The effect of the treatment was pronounced.
A mass effect was seen on x-ray.
Copyright (c) 2002 American Association for Medical
Transcription
It is confusing! I have been doing this for years and still have to stop and think at times. Good luck to you! You are getting into a great field of work! Hope you can get with a good company!
x3 per AAMT
Subject: x3 per AAMT
According to AAMT BOS use
Subject: According to AAMT BOS use
arabic numerals (not roman numerals) in this case.
See AAMT-BOS (sm)
Subject: See AAMT-BOS (sm)
Gleason tumor grade
Also known as Gleason score. The system scores or grades the prognosis for adenocarcinoma of the prostate, with a scale of 1 through 5 for each dominant and secondary pattern; these are then totaled for the score. The higher the score, the poorer the prognosis.
Lowercase grade or score, and use arabic numerals.
Diagnosis: Adenocarcinoma of prostate, Gleason score 8.
Gleason score 3 + 2 = 5.
Gleason 3 + 3 with a total score of 6.
without the S per AAMT-BOS (sm)
Subject: without the S per AAMT-BOS (sm)
eponyms
Names of entities—e.g., diseases, anatomic structures, operations, or tests— derived from the names of persons or places.
Homans sign
Lyme disease
Down syndrome
capitalization
Capitalize eponyms but not the common nouns, adjectives, and prefixes that accompany them.
Do not capitalize words derived from eponyms.
ligament of Treitz
red Robinson catheter
non-Hodgkin lymphoma
Parkinson disease but parkinsonism
Cushing syndrome but cushingoid
plurals
Do not use an apostrophe in the plural forms of eponyms.
Babinskis were negative.
possessive form
AAMT first advocated dropping the possessive form of eponyms in 1990. We adopted this standard because it promotes consistency and clarity. More recently, The AMA Manual of Style (1998), Stedman's Medical Dictionary (2000), and Dorland's Illustrated Medical Dictionary (2000), have acknowledged the trend away from the possessive form.
It is important to note, however, that use of the possessive form remains an acceptable alternative if dictated and/or if indicated as the preference by employer or client.
Apgar score
Babinski sign
Down syndrome
Gram stain
Hodgkin lymphoma
In awkward constructions, such as when the noun following the eponym is omitted, the possessive form becomes preferred.
The patient's husband suffers from Alzheimer's.
AAMT says...
Subject: AAMT says...
AAMT under cancer classifications has it as grade 1.
AAMT says...
Subject: AAMT says...
AAMT under obstetrics has it as gravida 1 or G1
62 mL - according to AAMT - nm
Subject: 62 mL - according to AAMT - nm
From AAMT
Subject: From AAMT
fractions
Spell out or use numerals for common fractions. Use the dictation style as a guide.
An hour and a half before presentation, the patient slipped and fell.
or Approximately 1-1/2 hours before presentation... (if dictated "one and a half hours" or "one and one-half hours")
The glass was two-thirds full. or The glass was 2/3 full.
7/8-inch wound
a half-inch incision or a 1/2-inch incision (since it was dictated precisely)
about a half inch below the sternal notch (the word about makes this an imprecise measurement)
He smokes a pack and a half of cigarettes per day.
or He smokes 11/2 packs of cigarettes per day.
or He smokes 1-1/2 packs of cigarettes per day.
Copyright (c) 2002 American Association for Medical Transcription
Per my AAMT BOS, gm is acceptable, sm
Subject: Per my AAMT BOS, gm is acceptable, sm
but g is the referred method (no period), which is the way I type it, i.e. Valtrex 1 g
Of course, my BOS is not the newest version, so things could have changed.
FYI-AAMT BOS, edition 2
Subject: FYI-AAMT BOS, edition 2
 Just thought I would pass on some information recently sent to me.
AAMT BOS (Book of Style), 2nd edition
periods
Do not use periods within or at the end of most abbreviations, including acronyms, abbreviated units of measure, and brief forms. Use a period at the end of abbreviated English units of measure if they may be misread without the period. Better still, write out most English units of measure, thereby avoiding this use of a period at the end of an abbreviation.
wbc
WBC
mg
exam
prep
inch preferred to in. (Do not use in meaning inch without a period.)
However, use periods in lowercase drug-related abbreviations.
b.i.d.
q.4 h. = note it is "q.4" and then a space before the "h."
p.o.
p.r.n.
If a sentence terminates with an abbreviation that requires a period, do not add another period.
He takes Valium 5 mg q.a.m.
not He takes Valium 5 mg q.a.m..
plurals
Use a lowercase s without an apostrophe to form the plural of capitalized abbreviations, acronyms, and brief forms.
EEGs
PVCs
CABGs
exams
Use 's to form the plural of lowercase abbreviations.
rbc's
Use 's to form the plural of single-letter abbreviations.
X's
Hyphens and adjectives
15-year-old boy
The patient is a 33-year-old.
2-year 5-month-old child (note no comma in this)
5-1/2-year-old girl
1-month course
.38-caliber pistol - note no leading zero here - see below
two-thirds full
one-half normal saline
half-normal saline
She was panic-stricken
20-pack-year history
self-medicated
shell-like
For quantities less than 1, place a zero before the decimal point, except when the number could never equal 1 (e.g., in bullet calibers and in certain statistical expressions such as correlation coefficients and statistical probability).
0.75 mg
.22-caliber rifle
the new AAMT BOS says about numbers....sm
Subject: the new AAMT BOS says about numbers....sm
that you should use 4-5 and not spell out four to five.....all numbers now, even 1 through 9, should be numerals and not spelling out four, five, etc.
quote from AAMT BOS
Subject: quote from AAMT BOS
eponyms
A name of a drug, disease, anatomic structure, operations, etc., derived from the name of the person or place. Do not use the possessive form.
Homans sign
Lyme disease
Parkinson disease
Cushing syndrome
ligament of Treitz
I went to an AAMT convention once and
Subject: I went to an AAMT convention once and
Someone asked her about that word, and she said never type pussy, type pus-filled or pus-like. That is what I have done ever since and never got dinged on QA for it.
As per AAMT book 2, is it x2 or x 2? TIA nm
Subject: As per AAMT book 2, is it x2 or x 2? TIA nm
x
AAMT Style
Subject: AAMT Style
Anyone have any good web links to sum up AAMT BOS Second Edition - Don't have book yet...Thanks
Probably AAMT's benefit.
Subject: Probably AAMT's benefit.
I have been an MT for over 25 years and this is crazy stuff. I just do what the clients/hospitals prefer. Too many AAMT guidelines and I feel some are just totally ridiculous.
Regarding AAMT rules
Subject: Regarding AAMT rules
I go with my client preference, and when I began working his account, the sample reports did not use BOS rules. I only use numerals to express drug dosage, measurements, dates, etc. I also agree with you on the appearance of it.
AAMT changes this every year when they want to--sm
Subject: AAMT changes this every year when they want to--sm
sell another version of the BOS. I go with client preferance, which is still spelling out 1-10 and numerical above 10. Dates are spelled out within the body of the report...client preference. AAMT is not the know all end all, just another money grabbing gimic! JMO
AAMT rule
Subject: AAMT rule
Just getting back into MT after a long hiatus and can't remember the rules when typing numbers. Is it okay to separate number values by commas, such as 1, 2, 3, etc.? (pathetic, I know.) TIA!
cannot find in AAMT BOS
Subject: cannot find in AAMT BOS
Overall, the medication has been well-tolerated or well tolerated?
Thanks!
Per AAMT BOS2
Subject: Per AAMT BOS2
Under "dangerous abbreviations" they would prefer mL instead of cc; thus, have changed it in my expansions and use it for all hospitals without anything to the contrary ever being said for about a year now.
and per BOS2 and AAMT for this we are not
Subject: and per BOS2 and AAMT for this we are not
not supposed to expand - unless your client profile says to - so if the dictator says I's and O's and it's verbatim - well....they get I's and O's. Most accounts today do not want over-expansions to pad lines. Of course, the client profile (CP) comes first or client preferences, but secondarily across the board - BOS2 keeps us all pretty uniformed....
See below taken from AAMT BOS2
Subject: See below taken from AAMT BOS2
Ordinals: Ordinal numbers are used to indicate order or position in a series rather than quantity.
Ordinals are commonly spelled out, especially when the series goes no higher than 10 items. However, as with all numbers in medical reports, AAMT recommends using numerals: 1st, 2nd, 3rd, 4th, etc.
Do not use a period with ordinal numbers.
3rd rib (or third)
5 th finger (or fifth)
She is to return for her 3rd (or third) visit in 2 days.
She was in her 9th (or ninth) month of pregnancy.
His return visits are scheduled for the 15th and 25th of next month.
The 4th cranial nerve...
From AAMT BOS2
Subject: From AAMT BOS2
followup, follow up
Use followup for the noun and adjective forms (the hyphenated form, follow-up is an acceptable alternative).
The patient did not return for followup. (noun)
In followup visits, she appeared to improve. (adjective)
For the verb, the two-word form follow up is the only correct choice.
We will follow up with regular return visits. (verb)
HINT: To test whether the correct form is one word or two, try changing the tense or number. If one or more letters must be added, the correct form is two words.
We will follow up.
tense change >>
We followed up.
(Followedup is not a word, so followed up must be two words.)
We follow up.
number change >>
He follows up.
(Followsup is not a word, so follows up must be two words.)
Per AAMT- BOS2
Subject: Per AAMT- BOS2
Express partial units as indicated.
D: grade 4 and a half over 6 murmur
T: grade 4.5 over 6 murmur
or grade 4.5/6 murmur
D: grade 4 to 5 over 6 murmur
T: grade 4 to 5 over 6 murmur
or grade 4/6 to 5/6 murmur
not grade 4-5/6 murmur
Per AAMT BOS2
Subject: Per AAMT BOS2
With periods for the latin abbreviation i.e.
q.i.d.
p.o.
b.i.d.
etc.
Per AAMT-BOS2...
Subject: Per AAMT-BOS2...
In particular, avoid the use of unnecessary or inappropriate capitals. Do not, for example, capitalize a common-noun reference to a thing or person if it is just one of many other such things or persons. Thus, emergency room and recovery room are not capitalized. Think of the rule for generic versus brand names for drugs. The generic term (common noun) emergency room is applied to all emergency rooms, so it is not capitalized.
Thus, I do not capitalize it unless it is with a facility name so I would say you are correct. Always exceptions to the rule according to the facility preference.
Per AAMT BOS2
Subject: Per AAMT BOS2
disk
Dictionaries and other reference works have long shown a lack of agreement about the spelling of this word. Some authorities prefer the spelling disc for references to the eye and disk for the spine. Others have an opposite preference.
We recommend the spelling disk for all anatomic and surgical references for this round, flat, regular, and regularly condensed plate of material.
There is classical support for this spelling. Disk is derived from the Greek diskos and came into our lexicon by way of medieval Latin (discos), whose alphabet does not include a k. Other English words ending in sk with similar derivation include ask, desk, kiosk, task, and whisk. By comparison, there are very few English words that end in sc.
optic disk
L4-5 disk space
diskectomy
diskitis
AAMT book says
Subject: AAMT book says
Use a hyphen for clarification.
after a prefix if it would have another meaning without the hyphen.
EX. re-cover (cover again)
recover (regain)
re-create (create again)
recreate (play)
or if there is an awkward combination of letters
EX. re-emphasize
re-evaluate
I would type retore. Hope this helps
Per AAMT BOS2
Subject: Per AAMT BOS2
Follow up versus follow-up; the hyphenated form is also an acceptable alernative.
Rest of the rules...
Followup, follow up: Use followup for the noun and adjective forms (the hyphenated form, follow-up is an acceptable alternative).
The patient did not return for followup. (noun)
In followup visits, she appeared to improve. (adjective)
For the verb, the two-word form follow up is the only correct choice.
We will follow up with regular return visits. (verb)
HINT: To test whether the correct form is one word or two, try changing the tense or number. If one or more letters must be added, the correct form is two words.
We will follow up.
tense change >>
We followed up.
(Followedup is not a word, so followed up must be two words.)
We follow up.
number change >>
He follows up.
(Followsup is not a word, so follows up must be two words.)
Per AAMT 2nd edition...
Subject: Per AAMT 2nd edition...
AAMT recommends dropping the period. See page 190.
Numbers per AAMT BOS...
Subject: Numbers per AAMT BOS...
Numerals, or figures, stand out from the surrounding text and serve a functional purpose in medical reports, where they should be used almost exclusively as opposed to spelled-out numbers:
She was seen in the emergency room 1 hour after the accident.
He tried 3 different medications without success.
The specimen weighed less than 2 pounds.
Arabic (per AAMT BOS)
Subject: Arabic (per AAMT BOS)
per AAMT, it is preferred to
Subject: per AAMT, it is preferred to
edit to read "x-ray again" as opposed to re-x-ray, but definitely not rex-ray or re-xray.
you are so right, but I thought AAMT
Subject: you are so right, but I thought AAMT
or whatever they call themselves today was doing that. Trouble is, they change the rules every so often. I am so sick of everybody doing this little power and money thing, making you scramble to keep up with all the new little changes like these given. It go to where everybody knew more about this than we did, or whoever was in power. I was surprised housekeeping did not change some of our rules sometimes! It got to where there was a knee jerk reaction to joint commission not liking abbreviations, so we were told they had banned all of them like we would not find out differently! Of course, we soon noticed we were the only ones not using them. I am talking things like SGPT and SGOT, for crying out loud. Then, of course, there is doctor preference which means the rules don't apply anyway. I don't see how all you people are keeping up with this crappola. Oh, and simple is only for everybody else; all we do is sit there and type, did you forget?!
Per AAMT-BOS2 (sm)
Subject: Per AAMT-BOS2 (sm)
Capitalize the word following the colon if it is normally capitalized, if it follows a section or subsection heading, or if the list or series that follows the colon
includes one or more complete sentences. Lowercase the first letter of each item
in a series following a colon when the items are separated by commas.
The patient is on the following medications: Theo-Dur, prednisone, Bronkometer.
ABDOMEN: Benign.
Pelvic examination revealed the following: Moderately atrophic vulva. Markedly
atrophic vaginal mucosa.
or Pelvic examination revealed the following: moderately atrophic vulva, markedly atrophic vaginal mucosa.
Per AAMT-BOS2 (sm)
Subject: Per AAMT-BOS2 (sm)
Lowercase stage and grade.
Use roman numerals for cancer stages. For subdivisions of cancer stages,add capital letters on the line and arabic suffixes, without internal spaces or hyphens.
stage 0 (indicates carcinoma in situ)
stage I, stage IA
stage II, stage II3
stage III
stage IV, stage IVB
Use arabic numerals for grades.
grade 1
grade 2
grade 3
grade 4
Write TNM expressions with arabic numerals on the line and a space after each number.
T2 N1 M1
T4 N3 M1
*If you have the ability to use AAMT-BOS2 it starts on page 50.
per AAMT-BOS2 65%-90%
Subject: per AAMT-BOS2 65%-90%
Per AAMT-BOS2
Subject: Per AAMT-BOS2
classification systems
Systematic arrangements into groups or classes.
See: cancer classifications, cardiology, obstetrics, and orthopedics.
Some classification systems use arabic numerals and others call for roman. In some systems there is no agreement on the use of roman versus arabic numerals. There is a trend away from the use of roman numerals, and generally speaking, the preference is for using arabic numerals unless it is documented that roman numerals are required. Several classification systems are listed below; check appropriate references for additional guidance.
Apgar score
Assessment of newborn's condition in which pulse, breathing, color, tone, and reflex irritability are each rated 0, 1, or 2, at one minute and five minutes after birth. Each set of ratings is totaled, and both totals are reported. Named after Virginia Apgar, MD.
Do not confuse with APGAR questionnaire for family assessment.
Use initial capital only.
Express ratings with arabic numerals.
Write out the numbers related to minutes, so that attention is drawn to the scores and confusion is avoided.
Apgars 7 and 9 at one and five minutes.
Ballard scale
A scoring system for assessing the gestational age of infants based on neuromuscular and physical maturity. Scores are converted to gestational age (in weeks).
Express in arabic numerals.
score age (weeks)
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
burn classifications
Burns are described as 1st, 2nd, 3rd, and 4th degree, according to burn depth.
AAMT recommends dropping the hyphen in the adjective form (e.g., 1st degree burn), though use of the hyphen is acceptable.
Expressing ordinals as numerals is preferred to writing them out: 1st, 2nd, 3rd, and 4th degree burns, not first, second, third, and fourth degree burns.
Rule of Nines: Formula, based on multiples of 9, for determining percentage of burned body surface. This formula does not apply to children because a child's head is disproportionately large.
head 9%
each arm 9%
each leg 18%
anterior trunk 18%
posterior trunk 18%
perineum 1%
Berkow formula: Rule of Nines adjusted for a patient's age. Assigns a higher percentage to a child's head, which is larger than an adult's head in proportion to its body.
Catterall hip score
Rating system for Legg-Perthes disease (pediatric avascular necrosis of the femoral head).
Use roman numerals I (no findings) through IV (involvement of entire femoral head).
Child classification of hepatic risk criteria
Classification of operative risk.
Capitalize Child (eponymic term), lowercase class, and capitalize the letter that follows.
Child class A
Child class B
Child class C
decubitus ulcers
Decubitus ulcers are classified using roman numerals from stage I (nonblanchable erythema of intact skin) through stage IV (full-thickness skin loss with extensive tissue destruction).
diabetes mellitus classifications
See: diabetes mellitus
Epworth Sleepiness Scale
Measures daytime sleepiness on a scale of 1 to 24. Use arabic numerals.
Less than 8: Normal sleep function
8-10: Mild sleepiness
11-15: Moderate sleepiness
16-20: Severe sleepiness
21-24: Excessive sleepiness
The patient's Epworth Sleepiness Scale is 16.
fracture classifications
See: orthopedics
French scale
Sizing system for catheters, sounds, and other tubular instruments. Each unit is approximately 0.33 mm in diameter.
Express in arabic numerals.
Precede by # or No. if the word "number" is dictated.
Do not lowercase French.
5-French catheter
#5-French catheter
catheter, size 5 French
Keep in mind that French is linked to diameter size and is not the eponymic name of an instrument. Thus, it is a 15-French catheter, not a French catheter, size 15.
Glasgow coma scale
Describes level of consciousness of patients with head injuries by testing the patient's ability to respond to verbal, motor, and sensory stimulation.
Each parameter is scored on a scale of 1 through 5, then totals are added together to indicate level of consciousness. (Glasgow refers to Glasgow, Scotland.)
score level of consciousness
14 or 15 normal
7 or less coma
3 or less brain death
global assessment of functioning (GAF) scale
A scale used by mental health professionals to assess an individual's overall psychological functioning. Typically reported in a psychiatric diagnosis as axis V.
Use arabic numerals 0 (inadequate information) through 100 (superior functioning in a wide range of activities).
Axis V GAF = 60 Flat affect.
See: diagnosis for a more complete discussion of psychiatric diagnoses.
global assessment of relational functioning (GARF) scale
This scale is used by mental health professionals to measure an overall functioning of a family or other ongoing relationship. Use arabic numerals from 0 (inadequate information) to 100 (relational unit functioning satisfactorily from self-report of participants and from perspectives of observers).
GVHD grading system
Graft-versus-host disease.
Use arabic numerals 1 (mild) through 4 (severe), placed on the line directly after the abbreviation (no space). May also be expressed as clinical grade 1 through 4.
GVHD1 or GVHD clinical grade 1
GVHD2 or GVHD clinical grade 2
GVHD3 or GVHD clinical grade 3
GVHD4 or GVHD clinical grade 4
Harvard criteria for brain death
In addition to body temperature equal to or higher than 32°C and the absence of central nervous system depressants, all of the following criteria must be met in order to establish brain death.
unreceptivity and unresponsiveness
no movement or breathing
no reflexes
flat electroencephalogram (confirmatory)
Hunt and Hess neurological classification
Classifies prognosis of patients with hemorrhage.
Write out and lowercase grade; do not abbreviate.
Use arabic numerals 1 through 4.
grade 3
Kurtzke disability score
Two-part scoring system to evaluate patients with multiple sclerosis.
Part one evaluates functional systems (pyramidal, cerebellar, brain stem, sensory, bowel and bladder, visual, mental, and other).
Part two is a disability status scale from 0 to 10.
Use arabic numerals.
magnitude scale
Measures earthquake magnitude. A one-unit increase on the scale equals a tenfold increase in ground motion.
Express with arabic numerals and decimal point.
She was injured in an earthquake measuring 6.6 magnitude.
Mallampati-Samsoon classification of airway
With the patient seated upright, mouth opened as wide as possible and tongue protruding, the anesthesiologist examines the airway—soft palate, tonsillar fauces, tonsillar pillars, and uvula—to evaluate the ease or difficulty of intubation: class I (easy intubation) through class IV (nearly impossible intubation).
Lowercase class and use roman numerals.
NYHA classification of cardiac failure
Use roman numerals I (asymptomatic) through IV (severe cardiac failure).
See: cardiology
Outerbridge scale
Assesses damage in chondromalacia patellae.
Lowercase grade.
Use arabic numerals 1 (minimal) through 4 (excessive).
Diagnosis: Chondromalacia patellae, grade 3.
physical status classification
A classification developed by the American Society of Anesthesiologists to classify a patient's risk of complications from surgery.
Lowercase class and use arabic numerals (1 through 5). The capital letter E is added to indicate an emergency operation.
class 1E
Rancho Los Amigos cognitive function scale
Neurologic assessment tool. Levels I through VIII are written with roman numerals.
I no response
II generalized response to stimulation
III localized response to stimuli
IV confused and agitated behavior
V confused with inappropriate behavior (nonagitated)
VI confused but appropriate behavior
VII automatic and appropriate behavior
VIII purposeful and appropriate behavior
social and occupational functioning assessment scale (SOFAS)
The SOFAS is an instrument used by mental health professionals to assess an individual's social and occupational functioning only.
See: global assessment of functioning (GAF) scale above
Use arabic numerals from 0 (inadequate information) through 100 (superior functioning in a wide range of activities).
TIMI system
See: cardiology terminology
trauma score
Scoring system that measures systolic blood pressure, respiratory rate and expansion, capillary refill, eye opening, and verbal and motor responses on a scale of 2 through 16. Score predicts injury severity and probability of survival.
Use arabic numerals.
Per AAMT-BOS2 (sm)
Subject: Per AAMT-BOS2 (sm)
Do not translate.
abbreviation Latin phrase English translation
a.c. ante cibum before food
b.i.d. bis in die twice a day
gtt. guttae drops (better to spell out drops)
n.p.o. nil per os nothing by mouth
n.r. non repetatur do not repeat
p.c. post cibum after food
p.o. per os by mouth
p.r.n. pro re nata as needed
q.4 h. quaque 4 hora every 4 hours
q.h. quaque hora every hour
q.i.d. quater in die 4 times a day
t.i.d. ter in die 3 times a day
u.d. ut dictum as directed
Note: We have inserted a space after the numeral 4 in q.4 h.
I guess the only way I would change it is if the client profile says to do so.
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