Unless you are to expand abbreviations
Posted By: see message on 2008-10-15
In Reply to: PT-INR - TheQUeen
Subject: Unless you are to expand abbreviations
you transcribe it as dictated.
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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.
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.
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"
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.
I always expand everything if CP says so, even lab tests..
Subject: I always expand everything if CP says so, even lab tests..
xx
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?
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)
According to the Stedman's abbreviations
Subject: According to the Stedman's abbreviations
& Acronyms it is
geriatric assessment unit
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.
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....
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?
Stedman's 3rd abbreviations has it both ways.
Subject: Stedman's 3rd abbreviations has it both ways.
nm
"Metastases" according to Stedman's Abbreviations
Subject: "Metastases" according to Stedman's Abbreviations
Page 8 under Abbreviations in BOS II, says to keep the periods
Subject: Page 8 under Abbreviations in BOS II, says to keep the periods
s
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