Abbreviations

The doctar I transcribe for tells me today that I have to stop abbreviating certain things that some kind of board has sent her a letter stating that it will have to stop. Has anyone else heard this? Like I can't use prn anymore I have to type as needed or bid or tid. I can't type Hx I have to type History. Stuff like that.

I can understand having to type out "history," but not p.r.n. But you can easily take care of that problem if you have an expander program or even in your auto correct if you use Word or quick correct if you use WordPerfect. Just type in hx and have it expand to history. Also, add prn and have it expand to the proper p.r.n. with the periods. Expander programs are great. I use Abbreviate with my job right now, but I have used several others that are great to. Shorthand is another good one, especially if you use it in conjunction with MedBrain. Basically, though, if the doctor dictates "as needed," you should type "as needed." If he says p.r.n., you should type p.r.n. But this is up to each site...they all have their acceptable abbreviations.

Hi Mercy, Generally if you type for a hospital, they are more strict about everything being spelled out (JCAHO guidlines). However, alot of times in private clinics, on office chart notes, abbreviations are used quite a bit. Actually I prefer to spell it out because it makes the report look more professional. The report has a potential of being read by many different people and not everyone knows what the abbreviations stand for. It takes a lot of time to look up abbreviations if they're used alot. Also, there's the danger of misinterpreting or misunderstanding the abbreviation. A simple one is I&D, does it mean incision and drainage or irrigation and debridement? Often you can tell from the context, but sometimes you can't......S&S could mean swish and spit OR it could mean swish and swallow. AC could mean three different chemo combinations (Adriamycin with either cyclophosphamide, carmustine, or cisplatin). For an outstanding resource to help you, I highly recommend a little book that I constantly use called "Medical Abbreviations by Neil M. Davis. He updates it all the time and you can order right over the Internet. Website: www.medabbrev.com (I think it costs around $17.) Neil lists some horror stories at the front of the book of how healtcare workers misinterpreted abbreviations and endangered the patient. He has a little section printed on the front cover that says..."73 YO WDWNAAF BIBA admitted to CPETU c/o PND & DOE. TBNA in EDTU last wk for CP relieved by NTG. Prev Adm for PTCA 1986, IATT 1997, & LARS 1999. ATSO Dr. Jones." I've been transcribing for over 30 years, and it would still take me quite some time to decipher that! (Can you imagine if it was an ER situation and they were trying to get the patient's history in a hurry?? Yikes!!) So thats some of the rationale behind spelling things out. Hoped it help, Mercy!

Ditto on the Medical Abbreviations book...It is a wonderful little tool. Also, after you purchase you, you have access to the updates on their website.