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Help! Need MME clarification - Anon


Posted: May 07, 2012

I try to make corrections according to MME feedback, which sometimes is conflicting and makes me nuts.  I have a question about diagnoses/impressions.  I know dictated abbreviations should be expanded. 

Dictated:  CAD with PCI and CABG.

Transcribed:  Coronary artery disease with PCI and CABG.

Corrected:  Coronary artery disease with percutaneous coronary intervention and coronary artery bypass grafting.

PCI and CABG are not diagnoses, but procedures, so why would they be expanded?

Obviously expanded is more characters ($$), but I don't want to be accused of unnecessary "padding."

Thanks!

 

 

 

 

 

I thought you expand - sm

[ In Reply To ..]
You would expand everything except for tests (MRI, PET scan, CBC).

You should expand all Dx and Procedure Titles in the Dx. - sm

[ In Reply To ..]
I believe you should expand all abbreviations except dosages or measurements actually.

Not our instructions. Leave lab tests like EMG - CBC, MRI

[ In Reply To ..]
and do NOT expand is what we were told.

Yes, correct. - MModal style guide

[ In Reply To ..]
If you are working for MModal, you have to follow their Style Guide which states to leave lab tests as abbreviation, otherwise expand as the 2 other posters stated.

Yes, leave lab tests, measurements, and dosages. Expand most - everything else. NM

[ In Reply To ..]
x

here's what it says in the transcription style guide - slave wages

[ In Reply To ..]
This is from the style guide from last October. If it has changed, I won't be surprised, of course, but this is what I'm going by right now (this is not the greatest example I don't think, because I would never dream of using "cabbage" for CABG).

Diagnostic headings: Assessment/Impression, Conclusion (of consultation), or Diagnosis(es)
Under diagnostic headings, expand only disease-related abbreviations or acronyms. Nondisease acronyms or abbreviations for procedures, tests, measurements, etc., are transcribed as dictated. Example: D: Impression: CAD status post cabbage, hypertension, COPD, and type two diabetes. T: Impression: Coronary artery disease status post CABG, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes.


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