Rehab note. He is using a lot of abbreviations. I am not able to document what they mean. *sm*
Posted By: mh on 2007-07-04
In Reply to:
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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For Rehab note....s/l SEBA score??
Subject: For Rehab note....s/l SEBA score??
He was placed on alcohol detox protocol and received tapering dose of Librium based on _____ scores.
It sounds like SEVA, SEBA or something like that?? Thanks for any help!
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
rehab d/s...s/l
Subject: rehab d/s...s/l
REhab help pls
Subject: REhab help pls
Recommendations: Physical therapy for pelvic stabilization, sitting with an s/l astoid james belt... Impression si joint dysfuntion in 19 week pregnant female with bilateral hip replacements...
rehab help
Subject: rehab help
Patient uses compensatory strategies for ADLs due to decreased vision but requires tactile and verbal cues for s/l timi-tech.
Thanks!
Rehab score
Subject: Rehab score
FIM score??
that's right .... land rehab nm
Subject: that's right .... land rehab nm
nm
S/L Metta Bench - Rehab DS
Subject: S/L Metta Bench - Rehab DS
For equipment given to patient, doc says: Patient given "METTA BENCH" and hospital bed, wheelchair.....
also sounds like MATTA, MEDDA, MADDA.
TIA!
no - he is in rehab for substance abuse...
Subject: no - he is in rehab for substance abuse...
There is nothing about law enforcement or any type of incarceration. Only that he is in in rehab and living at a rehab center.
Any Drug & Alcohol Rehab MTs out there?
Subject: Any Drug & Alcohol Rehab MTs out there?
I just started a job typing for a drug and alcohol rehab center. I am unfamiliar with a lot of this terminology and was wondering if there was anyone out there who is doing a similar account and would be willing to share their knowledge with me. Thanks.
Per rehab: In-exsufflator (Coughalator).
Subject: Per rehab: In-exsufflator (Coughalator).
I found a Burke Rehab in NY,
Subject: I found a Burke Rehab in NY,
(but I'm in NC).
http://www.burke.org/
type of score for rehab
Subject: type of score for rehab
Stating the pt had the following functional and "PENS" measure scores: Feeding 5, grooming 2, bathing 1
s/l land rehab measures? sm
Subject: s/l land rehab measures? sm
Doc is going to start her on some s/l land rehab measures for hip arthroscopy and femoroplasty.
If he is an alcoholic in rehab, technically
Subject: If he is an alcoholic in rehab, technically
he is probably not drinking at the moment, but agree it could have been worded a whole lot clearer.
plantigrade per Stedman's Ortho/rehab
Subject: plantigrade per Stedman's Ortho/rehab
tt
Stedman's Ortho & Rehab Words
Subject: Stedman's Ortho & Rehab Words
For all of the years I have typed in this for orthopods or any other documents including x-rays, it has always been patellofemoral. Hope this helps!
Stedman Ortho and Rehab words has it as--sm
Subject: Stedman Ortho and Rehab words has it as--sm
fabere test...not capitalized and no apostrophe s.
As to what? Mental health? Rehab? Lab results? nm
Subject: As to what? Mental health? Rehab? Lab results? nm
s
PT/Rehab uses the term scaption frequently..sm
Subject: PT/Rehab uses the term scaption frequently..sm
scaption means abduction (raising the arm away from the body) in the scapular plane. Not a documented word, but worked for a PT and PM&R physiatrist for years who used this terms. Maybe this dictator is botching this word and saying "scapitation" with the same meaning intended??
Help with rehab word s/l busy board
Subject: Help with rehab word s/l busy board
This is from my rehab account - "the patient is modified independent with s/l busy board transfers".
Any ideas?
TIA! This is my last one for today, I promise!
He saw ortho who then put him in a s/l ATSO brace, and he has had no rehab done since. Thanks
Subject: He saw ortho who then put him in a s/l ATSO brace, and he has had no rehab done since. 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"
Burke is THE rehab facility for Westchester, Putnam,
Subject: Burke is THE rehab facility for Westchester, Putnam,
s
Patient going into drug rehab. Will contact her s/l NA sponsor
Subject: Patient going into drug rehab. Will contact her s/l NA sponsor
Rehab hospital........Lisfranc and metatarsal fractures
Subject: Rehab hospital........Lisfranc and metatarsal fractures
nm
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.
Krackow's point, Sted's. Ortho and Rehab Words. nm
Subject: Krackow's point, Sted's. Ortho and Rehab Words. nm
s
You can try here for state listings of drug & rehab faciilties, see inside.
Subject: You can try here for state listings of drug & rehab faciilties, see inside.
http://www.usdrugrehabcenters.com/drug_rehab_centers/Michigan_drug_rehab_centers/index.html
How can I use something I can't document? nm
Subject: How can I use something I can't document? nm
.
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?
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