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Abbreviations in diagnosis - Usedtolovetranscription


Posted: Jan 25, 2010

When did this become okay?  I got called on my last QA that spelling out CVA or MI in the diagnosis is a no-no. 

Whoever signs the paychecks gets to make the rules. - nm

[ In Reply To ..]
nm

Who says its not okay? - ITA

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One of my accounts wants everything possible abbreviated in the diagnosis - H/O (history of), S/P (status post), DX/TX (diagnosis/treatment), SAR (seasonal allergic rhinitis), IBS, TIA, MI, LUQ, RUQ, LBP... and guess what?  They are his notes.  He can have them anyway he wants them.  And he is not "wrong." 


Another account - everything in the note, top to bottom, must be spelled out.  They too get their notes how they want them.  And they are not "right." 


The only beef you should have is if you were told one way and they are now dunning you for it, or if you were not instructed regarding this at all and used your own judgment ... which is fine, left to my own call I would spell everything out too.  But it is not written in stone that one way is right and the other way is wrong.


(Written in the BOS, maybe .. which many believe to be part of the stone tablets .. but BOS is not the absolute final say in wrong and right, it is just someone's idea of what should be done).

Thank you! - Ann

[ In Reply To ..]
Quote: (Written in the BOS, maybe .. which many believe to be part of the stone tablets .. but BOS is not the absolute final say in wrong and right, it is just someone's idea of what should be done).

Finally! Someone else who understands that the BOS is not a legally binding document.

It's just a guide that an employer can choose to follow in part or whole or not at all.

The poster who said that whoever signs the paychecks makes the rules was absolutely right.

old mt - old,tired MT

[ In Reply To ..]
What does the BOS say? Of course, whoever signs the check as mentioned above has the finaly say. I thought all diagnoses listed had to be written out too!

trying to save money. Sigh. Give them what they want. nm - Depends on the client specs. Maybe they are

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nm

The account that likes abbreviations (sm) - ITA

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Pays by the page, and his notes are always .. ALWAYS .. two pages.  Using abbreviations has never made 2 pages into 1.  So, in this case anyway, it is not about saving money ... it is simply personal preference. 


Which answers the OP's original question - "When did this become okay?"  It became okay when it is what your account/dictator decided that is what they want. 


The only thing that "has to be" done is following their specs, not what some book or organization tells you is The Right Way, The Only Way.



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