Wednesday, January 7, 2009

Medical Transcription Guidelines -5

Brief Forms and Medical Slang

1. Brief forms are shortened forms of legitimate words that can be documented in a reputable dictionary or have come into acceptance through usage. A slang term is either not listed in a dictionary or is designated as slang.

2. Medical slang should be avoided in medical documents for several reasons. A slang term may be obscure and might not clearly or accurately convey the intended meaning. Additionally, a slang term may be open to varied interpretations by different readers of the record, particularly obvious when a health record is subpoenaed by legal process.

3. Slang terms used disparagingly to refer to patients should be avoided. Physicians do not intend for offensive or offcolor remarks to be entered into a patient's health record.

4. Brief forms can be easily confused with medical slang. Physicians commonly use medical slang when discussing a patient's condition, but that does not mean the same slang term is acceptable in the medical report transcript.

5. Following are some terms that are currently deemed acceptable, unacceptable, or equivocal. A good rule to remember is, "When in doubt, write it out."

Acceptable Brief Forms

ab, AB abortion

bands band neutrophils

basos basophils

eos eosinophils

exam examination

lab laboratory

lymphs lymphocytes

monos monocytes

Pap smear Papanicolaou smear

polys polymorphonuclear leukocytes

prepped prepared

pro time prothrombin time

sed rate sedimentation rate

segs segmented neutrophils

Unacceptable Medical Slang

appy appendectomy

bili bilirubin

cath, cath'd catheter, catheterized

coags coagulation studies

crit hematocrit

cysto cystoscopy

DC, DC'd discharge(d), discontinue(d)

diff differential

dig ("dij") digitalis

echo echocardiogram

fib fibula, fibrillation

fluoro fluoroscopy

H. flu H. (Haemophilus) influenzae

H&H hemoglobin and hematocrit

lap laparotomy

lytes electrolytes

meds medications

mets metastases

Metz Metzenbaum scissors

multip multipara

nitro nitroglycerin

peds pediatrics

primip primipara

procto proctoscopy

retic reticulocyte

romied verb form of ROMI (rule out MI)

Rx prescription

script prescription

tabby therapeutic abortion

tib-fib tibia-fibula

tic diverticulum

trach(e) tracheostomy

V fib ventricular fibrillation

V tach ventricular tachycardia

Equivocal Medical Slang/Abbreviations

BP blood pressure

CA/ca carcinoma

chem chemistry

subcu. subcutaneous

subQ subcutaneous

temp temperature

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