Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Posted By: ss on 2008-01-18
In Reply to: pneumatic antiembolism stockings - MT50
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
ss
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
Help with IMPRESSION
Subject: Help with IMPRESSION
Should this be dictated like this?
1. Hyponatremia, rule out subdural hematoma.
OR
1. Hyponatremia.
2. Rule out subdural hematoma.
impression
Subject: impression
type it with a semicolon in between.
Impression
Subject: Impression
Hi Shirl -
Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.
Some usual headings in a radiology report are:
CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.
FINDINGS: or RESULTS:
IMPRESSION: or OPINION:
Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression
In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression
Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm
IMPRESSION prob
Subject: IMPRESSION prob
I have a problem under impression  ...
"D: IMPRESSION: Occipital neuralgia probable acute gastroenteritis"
question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?
NOTE: but the dictator did not dictate any numbering.... 
Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not? TIA!
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or
the a new section after it.
Thanks :)
Impression - hypertension
Subject: Impression - hypertension
This is under impression on a history and physical examination.
It is a numbered list.
[Sodiunduradine] is hypertension.
Any suggestions would be great!
It was under the impression section
Subject: It was under the impression section
I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.
Pt with mental retardation.
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.
it's impression and lung markings....
Subject: it's impression and lung markings....
No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.
impression, SP - status post
Subject: impression, SP - status post
nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression
Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression. Help appreciated.
Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.
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"
Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm
impression: bronchiolitis s/l sublets? or other process
Subject: impression: bronchiolitis s/l sublets? or other process
s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan
Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon
I was under the impression it was JCAH mandated to write ml instead of cc. NM
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM
Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"
Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM
(s/l shrowd ligament rupture).
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.
nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Subject: nevermind it's 'off' axis. He repeated it in the impression much more clearly!
I was under the impression that VAC is an acronym for vacuum-assisted closure.
Subject: I was under the impression that VAC is an acronym for vacuum-assisted closure.
Both Stedmans acronyms and Tessier surgical have it as VAC.
saw the patient, and the impression was s/l brass sediment impaction?(
Subject: saw the patient, and the impression was s/l brass sediment impaction?(
Firstly, would it be Impression: (instead of "colon") Negative mammography...
Subject: Firstly, would it be Impression: (instead of "colon") Negative mammography...
The dictation after just went straight into the impression, so I didn't include it. nm
Subject: The dictation after just went straight into the impression, so I didn't include it. nm
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
|
