Sunday, September 9, 2007

Abbreviations and Acronyms

Although certain acronyms (such as COPD or AIDS) might be widely used and understood, you should always think in terms of creating a patient record that leaves nothing open to misinterpretation. Clarity is of utmost importance.

One day a patient's medical record may need to be examined by a physician, nurse, attorney, or clerk who could misinterpret what you thought you dictated.

For instance:

A frequently dictated phrase used by cardiologists is "first degree AV block." Sloane's Medical Abbreviations and Eponyms lists the following interpretations for "AV."

a. alveolar duct

b. anteversion

c. aortic valve

d. arteriovenous

e. atrioventricular

f. auriculoventricular

g. avoirdupois

Items (a), (b) and (g) can quickly be ruled out. But should the medical transcriptionist choose (c), (d), (e), or (f)?

The answer might seem obvious to you because you know what thoughts are inside your head. However, few medical transcriptionists are clairvoyant.

Medical transcriptionists function as "interpreters" for numerous doctors practicing multiple specialties. Many of these physicians attended different medical schools.

When more than one term can accurately be used to describe something, chances are that some physicians want it used one way and some will want it used another. The results often lead to an angry call from a physician who bellows:

"Goddamnit, you're typing what I said
instead of what I want!"

Next: Brevity Inspires Clarity

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