Unless specifically told to expand, leave as GI.
Posted By: NM on 2008-03-25
In Reply to: referral to GI? - lola
Subject: Unless specifically told to expand, leave as GI.
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- referral to GI? - lola
- Unless specifically told to expand, leave as GI. - NM
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Wierd, I can specifically remember being told that:
Subject: Wierd, I can specifically remember being told that:
CVA was cerebrovascular accident
c.v.a. was costovertebral angle.
Been doing that for 25 years. Maybe it was just my original employer hospital's preference. Interesting, isn't it, that you can do something for years and years and never know it was not correct. I won't forget now, that is for sure. hehe
I was told to leave as satting
Subject: I was told to leave as satting
since most of my accounts have been verbatim and no expanding to saturation, etc. To me, sating would mean like to sate, i.e., to satisfy a desire or appetite.
Yes - agree leave off the "s" - thats what I was told too
Subject: Yes - agree leave off the "s" - thats what I was told too
Where I work we are told to leave things
Subject: Where I work we are told to leave things
as the dictator says, unless totally doesn't make sense. Sometimes it takes too much thought to think about how to rearrange a sentence. Obvious things like was/were and numbers at the beginning of sentences are changed, but things like you describe we leave.
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.
can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
Subject: can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
If it was dictated like that & you can leave abbrvns in, then leave it
Subject: If it was dictated like that & you can leave abbrvns in, then leave it
s
It does not say specifically, but sm..
Subject: It does not say specifically, but sm..
his pmhx is sig for diabetes, cardiac disease and hypertension.
Here is the list of meds the pt is on...Aciphex, Zantac, Domperidone which is a Canadian medication for treating the gastrointestinal tract, and also desifaremine.
This is probably specifically related to the
Subject: This is probably specifically related to the
x
not unless your clients specifically ask for such.
Subject: not unless your clients specifically ask for such.
x
Really? Even if the doc specifically says "ccs"
Subject: Really? Even if the doc specifically says "ccs"
you cannot assume 5-6 unless the doctor specifically
Subject: you cannot assume 5-6 unless the doctor specifically
5 to 6-mm nodule is the "most" correct. We all "know" the MD meant both values are mm but unless each value is specified, you cannot make that assumption.
he specifically said mri results went to the patient
Subject: he specifically said mri results went to the patient
weird, I know
I don't type enough labs to say specifically, but
Subject: I don't type enough labs to say specifically, but
Stedman's ABREV has URED - unable to read (lab result). Could that be what he's saying? Hope someone can verify one way or another, as I'm sure I'll have it eventually.
That's good, but no, he specifically says cadent at the end... : )
Subject: That's good, but no, he specifically says cadent at the end... : )
Just clostridium difficile....unless doc specifically says colitis. nm
Subject: Just clostridium difficile....unless doc specifically says colitis. nm
I agree with Lexiscan except that the doc specifically spells it. What do you think?
Subject: I agree with Lexiscan except that the doc specifically spells it. What do you think?
Found that, which would be my guess but he specifically spells WeTson. nm,
Subject: Found that, which would be my guess but he specifically spells WeTson. nm,
Nevermind, I am going to flag it as he specifically states "inhaler," thanks anyway.
Subject: Nevermind, I am going to flag it as he specifically states "inhaler," thanks anyway.
Does doc state this is specifically for the hypertension or does the patient have other problems thi
Subject: Does doc state this is specifically for the hypertension or does the patient have other problems this can be for?
Sounds good, but I specifically hear "fish." Thanks you two for trying! nm
Subject: Sounds good, but I specifically hear "fish." Thanks you two for trying! nm
nm
Tomby plate? He specifically says T as in Tom.. I have heard of Combi, any ideas?
Subject: Tomby plate? He specifically says T as in Tom.. I have heard of Combi, any ideas?
This is for fixation of trimalleolar ankle fracture. Any ideas?
The orthopedic doctor I transcribe for specifically spells it infra medial.
Subject: The orthopedic doctor I transcribe for specifically spells it infra medial.
.
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
Should we expand things like MRI and CT in diagnosis? SM
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.
I expand it, as no abbv in Diagnosis
Subject: I expand it, as no abbv in Diagnosis
nm
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
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