Per BOS2 - plus/minus not "+/-"
Posted By: no message on 2008-09-27
In Reply to: Should type as +/- - Maria
Subject: Per BOS2 - plus/minus not "+/-"
x
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minus to 40, maybe
Subject: minus to 40, maybe
nm
Yes, that is what he is saying, minus a few syllables. Thanks.
.
How do you type it when doc says plus minus, tia
Subject: How do you type it when doc says plus minus, tia
xxx
Ophthalmology - 20/40 minus or -?
Subject: Ophthalmology - 20/40 minus or -?
Is it correct to type out the word minus or do you use -?
Per BOS - plus/minus written out unless
Subject: Per BOS - plus/minus written out unless
x
plus/minus headache--I think
Subject: plus/minus headache--I think
Doc is dictating intake report and says the patient has "some s/l plus/minus headache along with weakness." Is there such a thing as a plus/minus headache? If so, how would I type it? Please help as all my QA editors seem to be having PMS or a midlife crisis and I'd like to avoid sending this one in :-)
We went with "minus 1-mm to minus 1.5-mm…" (nm)
Subject: We went with "minus 1-mm to minus 1.5-mm…" (nm)
x
I would go with minus 2-degree axis
Subject: I would go with minus 2-degree axis
/
Cervix 690 minus 1 with swelling. sm
Subject: Cervix 690 minus 1 with swelling. sm
Should I type this as 6.90 minus 1 with swelling? Just had the same doctor with another patient coming in with labor, and she says "Cervix is 390 and 0." That should be 3.90, meaning the cervical length, right? But what about this patient of 690 minus 1 with swelling? Is that cervical length of 6.90? Thank you.
thanks, is the minus a logical word tho?
Subject: thanks, is the minus a logical word tho?
x
how do you write left shoulder minus 30 ER?
Subject: how do you write left shoulder minus 30 ER?
how do you write left shoulder minus 30 ER?
BOS2........sm
Subject: BOS2........sm
MT50, I have the free download and couldn't find it. Would you tell me how you found it for next time. ty so much.
Per BOS2, 2nd, 3rd, etc.
Subject: Per BOS2, 2nd, 3rd, etc.
x
Thanks! I think my QA must be using BOS2.
Subject: Thanks! I think my QA must be using BOS2.
x
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....
not QA here but page 149 BOS2
Subject: not QA here but page 149 BOS2
Page 149 in Book of Style 2nd edition explains this in detail.
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 BOS2, no apostrophe after name
Subject: per BOS2, no apostrophe after name
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
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-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.
Per AAMT-BOS2 (sm)
Subject: Per AAMT-BOS2 (sm)
dollars and cents
Express exact amounts of dollars and cents with numerals, using a decimal point
to separate dollars from cents.
$4.56
When written out, lowercase all terms.
a million dollars
amounts less than $1
Use numerals; spell out and lowercase cents.
This was changed in BOS2 so has been
Subject: This was changed in BOS2 so has been
this way for a very long time.
you're right, pg 378 BOS2
Subject: you're right, pg 378 BOS2
units of measure are collective singular nouns and take singular verbs
Sorry, found it in BOS2 sm
Subject: Sorry, found it in BOS2 sm
Says NOT to hyphenate.
Thanks!
Agree with 1:100,000 as verified in BOS2. nm
Subject: Agree with 1:100,000 as verified in BOS2. nm
x
check out page 149 in the BOS2
Subject: check out page 149 in the BOS2
AAMT BOS2 says write it out...
Subject: AAMT BOS2 says write it out...
FYI - per BOS2, cc is a dangerous abbreviation
Subject: FYI - per BOS2, cc is a dangerous abbreviation
x
BOS2-Preference is disk.
Subject: BOS2-Preference is disk.
x
Per AAMT-BOS2 page 283 (sm)
Subject: Per AAMT-BOS2 page 283 (sm)
multiple digits
When dictated in a form such as “four point two thousand” or “five point eight million,” numerals may be transcribed in one of two ways:
4.2 thousand
or 4200
5.8 million
or 5,800,000
Per BOS2, hyphen is dropped, however
Subject: Per BOS2, hyphen is dropped, however
one of the accounts I work on what the hyphen. Another says there is no such word as follow-up and not to use it.
Per BOS2, the hyphen is no longer used.
Subject: Per BOS2, the hyphen is no longer used.
x
if you have BOS2, refer to the 'editing' section sm
Subject: if you have BOS2, refer to the 'editing' section sm
It mentions editing of slang words and phrases in verbatim dictation.
Stage T2b under last line of AAMT BOS2
Subject: Stage T2b under last line of AAMT BOS2
cancer classifications; suffixes
Per AAMT BOS2 cancer classifications...
Subject: Per AAMT BOS2 cancer classifications...
stage and grade
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
BOS2 says both breasts removed - mastectomies. nm
Subject: BOS2 says both breasts removed - mastectomies. nm
nm
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.
BOS2 says to redo the sentence: Guiac
Subject: BOS2 says to redo the sentence: Guiac
test performed on stool, Stool guiac was performed, etc. Any word like that the sentence should be reformated.
BOS2 says DO NOT abbreviate medication names.
Subject: BOS2 says DO NOT abbreviate medication names.
x
Yes that is the osteopenia score of the hip which can range between osteopenia between minus 1.0 and
Subject: Yes that is the osteopenia score of the hip which can range between osteopenia between minus 1.0 and minus 2.5.
Ringer. AAMT BOS2 rules on eponyms.
Subject: Ringer. AAMT BOS2 rules on eponyms.
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