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GI spelled out in diagnosis? - Serious MT
Posted: Aug 14, 2013
Hi -
Can't seem to find any mention of this in BOS3, but can someone tell me whether I should be using "GI" or "gastrointestinal" in a preoperative diagnosis? I seem to remember in school being told to leave GI as is when in the ROS but seem to be drawing a blank on this one! Thanks in advance!!
expand in diagnosis and impression - nm
[ In Reply To ..]Nm
BOS3 states to expand in diagnosis - sm
[ In Reply To ..]9.1.7 Report Section Titles
Write out an abbreviation in full if it is used in the admission, discharge, preoperative, or postoperative diagnosis; consultative conclusion; or operative title. These are critical points of information, and their meanings must be clearly communicated to ensure informed clinical decision-making, continuity of patient care, correct reimbursement, and accurate statistical data-gathering. Transcribe the diagnosis in full and include the dictated abbreviation in parentheses immediately following.
EXAMPLE
Dictated
Diagnosis CAD.
Transcribed
DIAGNOSIS
Coronary artery disease (CAD).
There are also exceptions, for example lab tests and units of measure do not need to be expanded.
expand? - diana
[ In Reply To ..]Do you have account specifics that you go by - that is what does your client want, or does the account strictly adhere to BOS? On the account I am on they do not want any abbreviations typed out anywhere, including in diagnosis/impression/assessment. What the client wants trumps all else.
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