Discharge Summary Abbreviations
Posted By: SG on 2007-08-13
In Reply to:
Subject: Discharge Summary Abbreviations
Must we expand all abbreviations in the Discharge Summary (as you would in a diagnosis/impression), or type verbatim?
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Discharge summary
Subject: Discharge summary
A diagnosis of pneumomediastinum, presumed from catheter placement, was made. An x-ray showed air under the (high , five, thigh) diaphragm. I can't make out what he's saying here, but those are the words it sounds like he's saying. Thanks.
A discharge summary. Thank you
Subject: A discharge summary. Thank you
x
discharge summary
Subject: discharge summary
pt. had cardiac cath
Condition upon discharge: Stable, up and walking without <bike line> complications.
Help please, very hard to understand ESL
discharge summary help
Subject: discharge summary help
Patient is a 46-year-old white female with past medical history significant for motor vehicle accident in 1976 with closed head injury profound mental retardation. Since then *** feedings at home. Started to have diarrhea a week prior to her admission S/L "onfactive" feedings at home any suggestions? thanks so much!!!
is this an OP or a discharge summary or what?
Subject: is this an OP or a discharge summary or what?
it is a discharge summary
Subject: it is a discharge summary
discharge summary
Subject: discharge summary
could possibly be "discharging Marcus John Doe" i.e. discharge summary?
discharge summary
Subject: discharge summary
I am working on a Discharge Summary and in the medication list "folic 12.5 one p.o. b.i.d." is listed. (This is a male pt.) I can't find 12.5 as a dosage available anywhere and also, isn't "folic" as in folic acid usually for women? the diagnoses are.... chf, cellulitis, cardiomyopathy and morbid obesity. I don't see what "folic" would be prescribed for. Any ideas? Thanks, this is driving me crazy!
discharge summary
Subject: discharge summary
I cannot make out this word at all. Any suggestions?
On admission his INR and PTT were both elevated and his hemoglobin and hematocrit were 12.9 and 38.1. We applied pressure dressingand gave 4 units of plasma. We then gave subcutaneous Vitamin K. The bleeding has stopped and we have *bal ized tip* and are sending him home on outpatient dialysis.
discharge summary
Subject: discharge summary
stabilized him?
discharge summary help
Subject: discharge summary help
does this sound right?
On admission his INR and PTT were elevated. His hemoglobin and hematocrit were 13.2 and 37.2. We applied pressure dressing and gave 7 units of fresh frozen plasma with vitamin K. The bleeding has since stopped overnight and we have *dialyzed him* this morning. We are sending him home to continue with his outpatient dialysis schedule.
Discharge Summary?
Subject: Discharge Summary?
I'm practicing an assignment for my class and I figured this was the best place to post a question about it.
I know that it's a discharge summary but I'm completely stumped as to the layout. It doesn't seem to fit the layouts in my books so I don't know what I should do. I don't want to get a bad grade on the assignment and would love to get the format right the first time.
If anybody is willing to, I would love to e-mail the file to you so you can possibly give me an idea?
word help please discharge summary
Subject: word help please discharge summary
Patient had more than 100,000 colonies of Gram-negative lactose negative rod **. at the end it sounds like sensitive see through. can that be right? thanks
Psych Discharge Summary
Subject: Psych Discharge Summary
Patient is status post total knee replacement and doctor is dictating regarding Hospital Course: She states, after preoperative medical clearance the patient was admitted. The patient underwent a lateral _______ of the left knee. S/L lateral litho of the left knee. She is really garbled. Any help would be appreciated. Thanks.
Psych Discharge Summary
Subject: Psych Discharge Summary
Thank you, thank you, thank you. I feel so braindead sometimes. It's like I just can't understand one more word.
Just a discharge summary stating pt had a uti with that type of bacteria, but nothing else.
Subject: Just a discharge summary stating pt had a uti with that type of bacteria, but nothing else.
xx
Discarge summary
Subject: Discarge summary
Eyes: The eyes have discharged bilaterally.
Could that be what he's saying?
S/L: M/S/S Hx: See summary report
Subject: S/L: M/S/S Hx: See summary report
any idea as to what this abbreviation could be? M/S/S Hx: See summary report.
Thanks
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).
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.
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