Should we expand things like MRI and CT in diagnosis? SM
Posted By: confused on 2008-06-27
In Reply to:
Subject: Should we expand things like MRI and CT in diagnosis? SM
After getting some things back from QA, I am a little unsure on this. Thanks.
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
I expand it, as no abbv in Diagnosis
Subject: I expand it, as no abbv in Diagnosis
nm
So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Subject: So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
Subject: Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
not sure in this case. Account goes by BOS, not super nitpicky, but I'm wondering what y'all do.
If that's what was said, yes. You'd expand the second one to 42,800 IF your QA allows it. If n
Subject: If that's what was said, yes. You'd expand the second one to 42,800 IF your QA allows it. If not,
s
if CP says to expand, I certainly do expand
Subject: if CP says to expand, I certainly do expand
Expand IV????
Subject: Expand IV????
How would I expand IV? "Plan is to discontinue his IV." When I look it up I get intravenous. That does not sound right......
THANKS!!!
Expand LVH
Subject: Expand LVH
Not sure whether to expand LVH in assessment. It does not appear expanded elsewhere in report. Left ventricular hypertrophy or left ventricular hyperplasia?? Leave as is?
Unless you need to know it to expand it in
Subject: Unless you need to know it to expand it in
the report, I wouldn't waste time over it. If you need to know, ask your supervisor to find out for you.
how do you expand L5-S1 in a DS?
Subject: how do you expand L5-S1 in a DS?
How would you expand this sentence in the Diagnosis section of a Discharge Summary.
Do I replace L5-S1 with lumbosacral joint?
My account gives examples that we should expand "Fracture, L2" out to "Fracture, second lumbar" .... so that is why I'm thinking I need to expand the L5-S1...
DIAGNOSES:
1. Right-sided L5-S1 herniated nucleus pulposus.
I never expand
Subject: I never expand
Because abbreviations can mean so many things, I never expand abbreviations even in a diagnosis. Our hospital determined it is the dictators job to edit before signing if they want it expanded.
expand HPI?
Subject: expand HPI?
Forgive my newbiness (that WILL become a word someday, I'm sure of it!) that will clearly be seen in this question!
When the doctor dictates "as stated in the HPI" , should I expand that to History of Present Illness - with those caps in place or only capitalizing the H?
Thanks!
should expand
Subject: should expand
I'm told to expand all those that are not common. (How gloriously vague!) Seems to me that "HPI" is pretty common. But I think I'll go ahead and expand.
So should I capitalize all of it?
I would expand
Subject: I would expand
ANY abbreviations the client wants expanded. Everyone has a preference.
If you expand it (and you should if your account allows), sm
Subject: If you expand it (and you should if your account allows), sm
it should be "cardiac catheterization," not "cardiac catheter."
only expand it out to metastasis if.....sm
Subject: only expand it out to metastasis if.....sm
Client profile dictates whether or not to give this dictator mets or metastasis.....his saying *met* was wrong. I would've given him *mets* unless the client profile allows expanding of words, and in that case I would've given them *metastasis*
I would expand all as you stated...
Subject: I would expand all as you stated...
I am not on a verbatim account and I do expand those types of abbreviations, but I would be interested in hearing others' opinions as well.
By the way, why are you "dubious"? Just curious!
I wouldn't expand it.
Subject: I wouldn't expand it.
Considering the context in which IV is used, it is its own entity. I would leave it as is.
I think I would just expand this nonsense to have it be
Subject: I think I would just expand this nonsense to have it be
s
I always expand it to saturating. (nm)
Subject: I always expand it to saturating. (nm)
xx
How to expand UBJ obstruction
Subject: How to expand UBJ obstruction
Hi! Need to type UBJ obstruction in an op note. Can't find anywhere in acronyms. Anyone know? Thanks in advance.
Unless you are to expand abbreviations
Subject: Unless you are to expand abbreviations
you transcribe it as dictated.
I always expand everything if CP says so, even lab tests..
Subject: I always expand everything if CP says so, even lab tests..
xx
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.
Expand BMI in op title? sm
Subject: Expand BMI in op title? sm
I couldn't resist putting Guess, since that's what I've had plenty of today. Guess who dictated this report and put in ? maybe the wrong ID? Or is it Dr. ??, or his/her (seriously, I can't tell) PA, or assistant...
Okay, I had to gripe. This is all I get lately. I have actually broken my own record for finding someone who stutters more than someone I used to work for. That's a terrible comparison, as everyone loved thiss doc and doc's dictation.
Thanks..
How do you expand DDAVP?
Subject: How do you expand DDAVP?
DDAVP is dictated in the assessment, in which no abbreviations are allowed. What is the expansion for DDAVP?
Guess I just won't expand it, still unsure....
Subject: Guess I just won't expand it, still unsure....
because too many times when he uses the term PFC there is no other indication of a joint replacement system having been done or anticipated, so I still have my doubts that that is really what he means by these initials. Thanks for your help.
I won't type slang, never have, never will -- expand
Subject: I won't type slang, never have, never will -- expand
Maybe "SK," but I'm not sure we have enough info to expand that. (sm)
Subject: Maybe "SK," but I'm not sure we have enough info to expand that. (sm)
I'm thinking they could be abbreviating a skin condition as "SK," but that could stand for a number of things (seborrheic keratosis [or keratoses], for one). Can't say....
I just expand to external fixator. I wonder if I'm wrong. nm
Subject: I just expand to external fixator. I wonder if I'm wrong. nm
x
I would expand it to saturating or saturations if allowed. nm
Subject: I would expand it to saturating or saturations if allowed. nm
s
I always expand stuff like that 'cause I'm a tool.
Subject: I always expand stuff like that 'cause I'm a tool.
Plus I like to get paid fer it...but mostly 'cause I'm an AAMT BOS tool ;-)
Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
Subject: Says this patient has previous CVT/CBT..have to expand and not sure what it could be for a PMH term,
any ideas?
Thanks
Unless specifically told to expand, leave as GI.
Subject: Unless specifically told to expand, leave as GI.
x
CBC with diff 4 *metas* -need to expand THANKSnm
Subject: CBC with diff 4 *metas* -need to expand THANKSnm
x
Probably saying "respiratory rate 20" and T-max would be correct or could expand to temperatur
Subject: Probably saying "respiratory rate 20" and T-max would be correct or could expand to temperature max.
x
oops, it's been a long day. Would you type "tox" or expand? nm
Subject: oops, it's been a long day. Would you type "tox" or expand? nm
nm
triple A=AAA, but I usual expand out to abdominal aortic aneurysm.
Subject: triple A=AAA, but I usual expand out to abdominal aortic aneurysm.
x
If not verbatim and you're sure of meaning, expand it and get paid for the characters. nm
Subject: If not verbatim and you're sure of meaning, expand it and get paid for the characters. nm
s
If verbatim then that is correct. If you have to expand (as in my account) it is maximum temperature
Subject: If verbatim then that is correct. If you have to expand (as in my account) it is maximum temperature. (nm)
x
Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
Subject: Depends on your account specifics. If they allow you to expand, that's fine, but it is straight
hardcore verbatim you have to leave it as is, whether it looks ugly or not. I know, I really don't like it when they abbreviate left and right, leave words off sentence structures so they can speak faster and get it over with.
I expand CC to cubic centimeters or milliliters depending on which is correct.
Subject: I expand CC to cubic centimeters or milliliters depending on which is correct.
I always spell abbreviations out such as this one that follows a vague number , i.e., few, several, many, etc. It just doesn't look right having the abbreviation in that sort of sentence to me. If you adhere to the BOS, it suggests spelling them out in this instance as well.
Can't do that, as these things are sm
Subject: Can't do that, as these things are sm
not in my old books but this MedCompare site has trademarked links etc.
http://www.medcompare.com/news.asp?newsid=121708
things it might be
Subject: things it might be
PROCEDURE: Medial branch block of the L4-5 and L5-S1 facets on the right under fluoroscopic guidance. Might just be saying that is the scheduled procedure.
(ob-suse) might have started saying operating suite?
And probably should be prone position.
Could be two things, sm.
Subject: Could be two things, sm.
If the doc is excising the area, they will say "wide local excision" or "wide excision" for short. If talking about a scar, sometimes the scar becomes wider with time so it would be "widened incision."
I think they are two different things
Subject: I think they are two different things
MU would be milliunits which is, I believe, one thousandth of a unit. This is millions of units. I think??
Things to try:
Subject: Things to try:
googling "unison antibiotic" or "unison medication," or
doing a search in Stedman's for "un*s*n"
or using WebMD
http://www.webmd.com/drugs/index-drugs.aspx
-- when I put the letters "un" into the search box, the 3rd item is "Unasyn IV.
I use the 'd for things like that OR you can
Subject: I use the 'd for things like that OR you can
say the patient was brought by air-vac to XXX or something to that effect.
Might be several things. sm
Subject: Might be several things. sm
"but as per patient these were thought to be stable? or benign?
"but according to the patient =======
It can mean other things too...sm
Subject: It can mean other things too...sm
Here is a link to check out:
http://www.fairview.org/healthlibrary/content/ca_hemodyna_car.htm
There are many reasons why hemodynamics are affected. It is not just limited to blood pressure, but that is one of the top answers and a very good answer.
2 things...
Subject: 2 things...
is there a such thing as "S and wave changes"
also, s/l "pre-lectrical-thiket function is normal". These are from a stress test which is stressing me out!
thank you - another one of those things that's
Subject: thank you - another one of those things that's
difficult to verify on the web, ya know!
|
