Sunday, December 28, 2008

Medical Transcription Guidelines 1


1. Abbreviations, acronyms, and initialisms are frequently dictated in medical reports and are an integral part of medicine. When abbreviations are dictated, Transcriptionists should consult their reference books for their meanings and memorize them for future use.

2. Many medical transcriptionists readily type abbreviations verbatim when dictated. Some transcriptionists prefer to translate most abbreviations and brief forms when dictated, believing that abbreviations obscure the clarity of the medical report and make it imprecise. Many facilities require the translation of abbreviations, especially when they appear in the diagnosis or impression section of a report.

In rare instances, the translation of abbreviations may cause confusion rather than achieve clarity. For example, VDRL is readily recognized as a laboratory test for syphilis and it is not necessary or desirable to translate it, even in a diagnosis or impression.

3. The first time an uncommon abbreviation is used within a report, the transcriptionist may transcribe it as dictated and translate it in parentheses following the abbreviation. The abbreviation may then be used without further translation in the report that follows.

Dictated: This patient was seen for PVH.

Transcribed: This patient was seen for PVH (persistent viral hepatitis).

4. When an abbreviation is dictated in the diagnosis or impression, it should be translated for clarity.

Dictated: DIAGNOSIS: Status post TAH, BSO.

Transcribed: DIAGNOSIS: Status post TAH, BSO (total abdominal hysterectomy, bilateral salpingo-oophorectomy).

5. Occasionally, an abbreviation may have more than one translation. If the abbreviation the physician is using has a widely recognized meaning, and if the meaning of the abbreviation is perfectly clear within the context of the report, it probably does not need to be translated. However, it is usually acceptable to expand abbreviations to promote clarity of the medical document. For uncommon abbreviations, the abbreviation may be typed as dictated and the translation placed in parentheses following the abbreviation.

Dictated: The patient suffers from PND, which causes chronic sore throats.

Transcribed: The patient suffers from PND (postnasal drainage), which causes chronic sore throats.

Dictated and Transcribed: The patient suffers from orthopnea, PND, and nocturnal dyspnea.

In the latter example, it is not necessary to translate PND because the reader will understand that PND in this context refers to paroxysmal nocturnal dyspnea, not postnasal drainage. It would be acceptable, however, to translate the abbreviation for clarity.

6. Medical abbreviations are written in several ways. The three most common include all capital letters, a combination of capital and lowercase letters, and all lowercase letters with periods. Seldom are periods used with uppercase abbreviations. Periods are generally not used with combination uppercase and lowercase abbreviations, with the exception of Ph.D.

p.o. b.i.d by mouth twice daily

q.h.s. every night at bedtime

KCl potassium chloride

CHF congestive heart failure

7. The abbreviations for intravenous and intramuscular are written without periods (IV, IM) for simplicity by many transcriptionists, or with periods (I.V., I.M.) to avoid I.V. being misread as roman numeral four (IV). References are inconsistent, at times writing them with periods and at times without. Both forms are acceptable, but the transcrip-tionist should be consistent in usage within a report.

IV, IM; I.V., I.M. (intravenous, intramuscular)

8. An acronym is a word formed from the first letters of other words. Acronyms are initially formed with capital letters, but after they gain acceptance as words, they are sometimes converted to lowercase letters and their origin as initialisms is forgotten.

AIDS (acquired immunodeficiency syndrome)

CABG ("cabbage"-coronary artery bypass graft)

ELISA (enzyme-linked immunosorbent assay)

fabere (flexion-abduction-external rotation-extension) test

laser (light amplification by stimulated emission of radiation)

simkin (simulation kinetics) analysis

9. To make an abbreviation plural, simply add the letter s with no apostrophe if the abbreviation is in all capital letters. If the abbreviation (M.D., for example) ends in a period, add an apostrophe and s (M.D.'s).

A series of CBCs (complete blood counts) was ordered.

DTRs (deep tendon reflexes) were 3+ and equal bilaterally.

IVs (or I.V.'s) were ordered to run TKO (to keep open).

Three M.D.'s were invited to speak.

10. When abbreviations are used with numbers for medication dosage times, use periods.

q.4h. or q. 4 hr. (every 4 hours)

q.12h. or q. 12 hr. (every 12 hours)

11. An abbreviation, such as the name of a lab test, dictated at the beginning of a sentence or in the body of a report may be transcribed as dictated if its meaning is clearly understood. If abbreviations are not dictated, the transcriptionist should not supply them. Exception: metric units of mea-sure, which are routinely abbreviated.

ST depression was noted on EKG.

SGOT was elevated at 60 IU/dL.

CBC and electrolytes were within normal limits.

12. If the dictator abbreviates the title of a major heading within a report, the transcriptionist should translate the abbreviation.

Dictated: HPI

Transcribed: History of Present Illness

13. Abbreviating metric measurements accompanied by numerals is preferred in medical reports. Abbreviations for metric measurements contain no periods and have the same form for singular and plural usage.

kg (kilogram)(s) cc (cubic centimeter)(s)

g (gram)(s) cm (centimeter)(s)

mg (milligram)(s) mEq (milliequivalent)(s)

14. Do not abbreviate a metric measurement if no specific numeral is dictated.

The scar was several centimeters in length.

15. Standard English units of measure (inch, foot, pound) are so short that they are usually spelled out, although foot and pound are correctly abbreviated ft. and lb., respectively (note the periods). The standard abbreviation for inch is in., although it is recommended that it not be used in medical reports as it is too easily confused with the preposition in. Exception: It is common to use the abbreviation for pounds (lbs.) and single and double quotation marks for feet and inches in presenting weight and height figures in medical reports.

Weight 120 lbs., height 5'2".

1 comment:

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