• When anatomic position is described in terms of clockface orientation, used o’clock
E.g: The incision was made at the 3 o’clock postion.
• Don’t used o’clock words if position is subdivided.
D: The cyst was found at the 2:30 o’clock position. T: The cyst was found at the 2:30 position.
Thursday, February 19, 2009
CONTRACTIONS
• Avoid “contraction” exept in direct quotations.
E.g. The mother reported, “He’s been hysterical.”
• If possible EXTEND Abbreviation that contain contraction.
D: The patient OD’d on Valium. T: The patient overdosed on Valium.
D. Stool was guaiac’d. T: Guaiac test was done on the stool.
E.g. The mother reported, “He’s been hysterical.”
• If possible EXTEND Abbreviation that contain contraction.
D: The patient OD’d on Valium. T: The patient overdosed on Valium.
D. Stool was guaiac’d. T: Guaiac test was done on the stool.
DATES
Punctuation
• When month, date & year are given in this sequence, set off the year by COMMA. Do not used Ordinals.
D: She was admitted on December 14th 2003 T: She was admitted on December 14, 2003.
• NO COMMA on military date or no year was given.
T: She was admitted in December 2001.
T: She was admitted on 14 December 2001.
• NO punctuation after year if date STAND alone.
T: ADMISSION DATE: April 3, 2000
T:DISCHARGE DATE: APRIL 14, 2000
Ordinals
• Use ordinals when day of month precedes the month us preceded by “THE, Do nor use commas.
• Do not use ordinals in month/day/year format.
T: the 4th of April 2001 not April 4th, 2001
Military Style
• Military style used – day precedes by month
• No ordinals in day/month/year format.
• Use numerals not common.
T: 4 April 2001
T: 4 Apr 2001
In Text
• Preferable to spell out dates used in the body of a report.
• Writing out the name of the month and in using four digits for the year.
T: The patient is previously seen on April 14, 2001.
• When month/day are dictated- as is. add the year only if you are certain.
D: The patient was last seen on April 4th. T: The patient was last seen on April 4, 2003.
• Date used repeatedly – expressed as numerals separated by virgules or hyphens as long as they clearly understood.
T: Electrolytes on April 23, 2001, revealed a sodium of 135, potassium 4.3, bicarbonate 25, chlorides 102. Repeated on 4/35 and again on 4/26. Electrolytes remained within normal limits.
End of line
• Avoid dividing between month and day.
• When month, date & year are given in this sequence, set off the year by COMMA. Do not used Ordinals.
D: She was admitted on December 14th 2003 T: She was admitted on December 14, 2003.
• NO COMMA on military date or no year was given.
T: She was admitted in December 2001.
T: She was admitted on 14 December 2001.
• NO punctuation after year if date STAND alone.
T: ADMISSION DATE: April 3, 2000
T:DISCHARGE DATE: APRIL 14, 2000
Ordinals
• Use ordinals when day of month precedes the month us preceded by “THE, Do nor use commas.
• Do not use ordinals in month/day/year format.
T: the 4th of April 2001 not April 4th, 2001
Military Style
• Military style used – day precedes by month
• No ordinals in day/month/year format.
• Use numerals not common.
T: 4 April 2001
T: 4 Apr 2001
In Text
• Preferable to spell out dates used in the body of a report.
• Writing out the name of the month and in using four digits for the year.
T: The patient is previously seen on April 14, 2001.
• When month/day are dictated- as is. add the year only if you are certain.
D: The patient was last seen on April 4th. T: The patient was last seen on April 4, 2003.
• Date used repeatedly – expressed as numerals separated by virgules or hyphens as long as they clearly understood.
T: Electrolytes on April 23, 2001, revealed a sodium of 135, potassium 4.3, bicarbonate 25, chlorides 102. Repeated on 4/35 and again on 4/26. Electrolytes remained within normal limits.
End of line
• Avoid dividing between month and day.
DEGREES
Burns
• Described 1st, 2nd,3rd or 4th degree.
Eg. 1st degree burn
• Dropping hypen in adjective form.
Eg. 2nd –degree burn
Orthopedics
• Write out degrees or use of degree sign (º).
Eg. The patient was able to straight leg raise to 40 degrees to 40º.
Temperature
• Express w/ numerals except for zero.
• No space between degree symbol and temperature scale.
T: zero degrees 36 degrees 36ºC
• Use minus to indicate temperature below zero.
T: minus 48ºC
• If temperature scale (Celsius, Fahrenheit, Kelvin) or abbreviation (C,F,K) not dictated. It’s not necessary to insert it.
• Described 1st, 2nd,3rd or 4th degree.
Eg. 1st degree burn
• Dropping hypen in adjective form.
Eg. 2nd –degree burn
Orthopedics
• Write out degrees or use of degree sign (º).
Eg. The patient was able to straight leg raise to 40 degrees to 40º.
Temperature
• Express w/ numerals except for zero.
• No space between degree symbol and temperature scale.
T: zero degrees 36 degrees 36ºC
• Use minus to indicate temperature below zero.
T: minus 48ºC
• If temperature scale (Celsius, Fahrenheit, Kelvin) or abbreviation (C,F,K) not dictated. It’s not necessary to insert it.
DIAGNOSIS
Abbreviation in diagnoses
• No abbreviation for diagnostic term in document section designating impression, admission diagnosis, discharge diagnosis, preoperative diagnosis, and postoperative diagnosis.
• Transcribed it as dictated if you cannot determine the meaning of a dictated abbreviation or acronym.
D: Operation. Left BK A T: Operation: Left below- knee amputation.
• Some descriptive terms rel to diagnosis may be abbreviated. Use abbreviation for units of measure.
Diagnosis: Laceration, 5 mm, Left abdomen.
Numbering diagnosis
• If plural form diagnoses if more than one listed. If one only diagnosis.
• It is preferable not to number one diagnosis even if a number is dictated. If there are several diagnoses, it is preferable to number them even if the numbers are not dictated.
E.g : DIAGNOSIS: Appendicitis
T: DIAGNOSES:
1. Appendicitis.
2. History of coronary artery bypass graft (CABG).
Psychiatric Diagnoses
• A multiaxial system is often used in diagnosis psychiatric patients:
Axis I: All psychiatric disorders.
Axis II: Personality disorders & Mental retardation.
Axis III: General medication condition.
Axis IV: Psychosocial and Environmental problems.
Axis V: Assessment of functioning, usually global assessment of functioning (GAF) scale.
• Dictated along w/ applicable diagnostic codes found in Diagnostic Statistical Manual of Mental Disorders
Axis I: 296.2 Major depressive disorder, single episode, severe without psychotic features.
305.0 Alcohol Abuse.
Axis II: 301.6 Dependent personality disorder.
Axis III: None.
Axis IV: Threat of job loss.
Axis V: GAF 53 (current)
Differential diagnosis
• When patient present w/in group of symptoms and diagnosis is unclear, the clinician may refer in medical report to the differential diagnosis in order to compare and contrast the clinical finding of each. Although it consists of two or more possible diagnoses, the term differential diagnosis takes a singular verb.
T: The differential diagnosis was….
“Same”
• Do not transcribed “same” when dictated for the discharge diagnosis - repeat diagnosis in full.
D: Admission diagnosis: Left testicular hernia.
Discharge diagnosis: Same.
T: ADMISSION DIAGNOSIS: Left testicular hernia.
DISCHARGE DIAGNOSIS: Left testicular hernia.
• Beware of similar incomplete statements w/in names of operations and transcribed them in full.
D: Operation performed : Repair of same.
T: OPERATION PERFORMED: Repair of left testicular hernia.
• No abbreviation for diagnostic term in document section designating impression, admission diagnosis, discharge diagnosis, preoperative diagnosis, and postoperative diagnosis.
• Transcribed it as dictated if you cannot determine the meaning of a dictated abbreviation or acronym.
D: Operation. Left BK A T: Operation: Left below- knee amputation.
• Some descriptive terms rel to diagnosis may be abbreviated. Use abbreviation for units of measure.
Diagnosis: Laceration, 5 mm, Left abdomen.
Numbering diagnosis
• If plural form diagnoses if more than one listed. If one only diagnosis.
• It is preferable not to number one diagnosis even if a number is dictated. If there are several diagnoses, it is preferable to number them even if the numbers are not dictated.
E.g : DIAGNOSIS: Appendicitis
T: DIAGNOSES:
1. Appendicitis.
2. History of coronary artery bypass graft (CABG).
Psychiatric Diagnoses
• A multiaxial system is often used in diagnosis psychiatric patients:
Axis I: All psychiatric disorders.
Axis II: Personality disorders & Mental retardation.
Axis III: General medication condition.
Axis IV: Psychosocial and Environmental problems.
Axis V: Assessment of functioning, usually global assessment of functioning (GAF) scale.
• Dictated along w/ applicable diagnostic codes found in Diagnostic Statistical Manual of Mental Disorders
Axis I: 296.2 Major depressive disorder, single episode, severe without psychotic features.
305.0 Alcohol Abuse.
Axis II: 301.6 Dependent personality disorder.
Axis III: None.
Axis IV: Threat of job loss.
Axis V: GAF 53 (current)
Differential diagnosis
• When patient present w/in group of symptoms and diagnosis is unclear, the clinician may refer in medical report to the differential diagnosis in order to compare and contrast the clinical finding of each. Although it consists of two or more possible diagnoses, the term differential diagnosis takes a singular verb.
T: The differential diagnosis was….
“Same”
• Do not transcribed “same” when dictated for the discharge diagnosis - repeat diagnosis in full.
D: Admission diagnosis: Left testicular hernia.
Discharge diagnosis: Same.
T: ADMISSION DIAGNOSIS: Left testicular hernia.
DISCHARGE DIAGNOSIS: Left testicular hernia.
• Beware of similar incomplete statements w/in names of operations and transcribed them in full.
D: Operation performed : Repair of same.
T: OPERATION PERFORMED: Repair of left testicular hernia.
EXPONENTS
• Exponents are generally superscripted, but if not available, use appropriate abbreviation (cu or sq) instead.
10 5 or 10 to the 5th 4 cm2 or 4 sq cm
10 5 or 10 to the 5th 4 cm2 or 4 sq cm
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