Clarification - Hopital Course - leave abbreviations?
Posted By: SG on 2007-08-13
In Reply to: Discharge Summary Abbreviations - SG
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!!!!!!
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can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
Subject: can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
clarification
Subject: clarification
"... the lacertus fibrosus (bicipital fascia), which passes obliquely downward and medialward across the brachial artery, and is continuous with the deep fascia covering the origins of the Flexor muscles of the forearm..." per Gray's Anatomy. Hope this helps.
all right, thanks for the clarification
Subject: all right, thanks for the clarification
clarification
Subject: clarification
Does the following make sense? Fundi: Did have some status post laser therapy of the cerumen occlusion in the left ear.
clarification
Subject: clarification
I mean like a bedroom "air mattress"
Clarification, please
Subject: Clarification, please
You listed this:
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.
It says 'lowercase the first letter of each item in a series...but Theo-Dur has a capital letter...can you please tell me which of my examples is correct? Thanks
Further Clarification
Subject: Further Clarification
I think I am just confusing the issue for you. Here is what the BOS says about Military time. Maybe this is more helpful.
"Military time identifies the day's 24 hours by numerals 0100 through 2400. Hours 0100 through 1200 are consistent with a.m. hours 1 through noon, while hours 1300 through 2400 correlate with p.m. hours 1 through midnight.
This form takes four numerals. Do not separate hours from minutes with a colon. Do not use a.m. or p.m."
In my previous post I made a mistake, I told you if the number started with a 1 0r a 2 it was p.m. - that is not true. 1000 hours is 10 a.m. 1100 hours is 11 a.m. and 1200 hours is noon. 1300 hours is 1 p.m. etc...
If it was dictated like that & you can leave abbrvns in, then leave it
Subject: If it was dictated like that & you can leave abbrvns in, then leave it
s
SM for quick clarification...
He has a long-standing problem. However, his problem is of long standing.
(Just thought I'd mention it.) *grin*
clarification of verbatim!!
Subject: clarification of verbatim!!
I am told to type some test files verbatim and I know that means exactly the way the dictator is saying it. My problem is the doctor is saying ain't and doesn't, which are contractions. This just do not seem right, right?
clarification of my response
Subject: clarification of my response
I would leave it as you have it if the doctor is talking about two different fingers, which was my assumption. In my experience, doctors like to omit the word and a lot and commas are substituted. If he/she is taking about the same finger, then omit the comma.
Clarification - s/l hindru intox
Subject: Clarification - s/l hindru intox
To clarify, I need help with this:
He was found to be in rhabdomyolysis and s/l hindru intox was positive for amphetamines, benzos, opiates, and THC.
Thanks!
Clarification - s/l symptom status
Subject: Clarification - s/l symptom status
To clarify, I need help with this:
He smiles much of the time; he is cooperative. s/l Symptom status revealed that he knew that George Bush was the current president and that Bill Clinton preceded him. He denies hearing any voices.....
Thanks!
I stand corrected. Thanks for the clarification on that! nm
Subject: I stand corrected. Thanks for the clarification on that! nm
.
jg, thanks for that clarification. It makes sense.
Subject: jg, thanks for that clarification. It makes sense.
Thanks
For further clarification, per AAMT BOS2 if there is a value associated with this abbreviation it sh
Subject: For further clarification, per AAMT BOS2 if there is a value associated with this abbreviation it should be sq cm, i.e. 2 sq cm not 2 cm2 as too many numerals may cause confusion and not be easily read.
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.
In the diagnosis, I would (no abbreviations)
Subject: In the diagnosis, I would (no abbreviations)
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.
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