MT Slang or Technical Term?

Grammar / MT Daily Homepage /

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Some of us are sorting out this distinction: When should we allow the short form, when should we expand? What dictionary would give a patient the definition of these words? Is JCAHO really silent on this? Are doctors risking legally to use this jargon? Should MTs just shut up and type what they hear or be thoughtful, expert editors? Are we padding our line counts when we write everything out?

Medications: (Most agree these should be expanded in transcription)
vanc = vancomycin, gent = gentamicin, pen = penicillin, epi = epinephrine, dig = digitalis/digoxin, amox = amoxicillin, terb drip = terbutaline drip, theo = theophylline
Diagnoses and operative procedure titles: (should be expanded in transcription)
ex lap = exploratory laparotomy, vag-hys = vaginal hysterectomy, flex sig = flexible sigmoidoscopy, lami = laminectomy, lac = laceration, accels = accelerations, decels=decelerations, osteo=osteoporosis.
What about these?
C-section = cesarean section, T-spine = thoracic spine, C-spine = cervical spine, L-spine = lumbar spine, exam = examination, prepped = prepared, quads = quadriceps, neuro= neurologic/neurology/neurosurgical, endo = endoscopy, circ = circumflex, brady = bradycardia, labs = laboratory studies, T-max, = temperature maximum, bicarb = bicarbonate, retic = reticulocyte count, reticking = producing reticulocytes, fluoro = fluoroscopy, consult = consultation, pulse ox = pulsed oximetry, postop = postoperative, preop = preoperative, feeds = feedings, H. flu = Haemophilus influenzae, hep-B = hepatitis B, hep-C = hepatitis C, H. pylori = Helicobacter pylori, C. diff = Clostridium difficile, E. coli = Escherichia coli, dip, dexi = Dextrostix/dipstick, micro = microscopic analysis, tox = toxicology, toxo = toxoplasmosis, coags = coagulation factors, lytes = electrolytes, staph = Staphylococcus, staph epi = Staphylococcus epidermidis, strep = Streptococcus, V-tac = ventricular tachycardia, A-fib = atrial fibrillation, triple-A = abdominal aortic aneurysm, neb = nebulizer, plastics = plastic surgery, dc and dc'd = discontinue/discharge, bicarb = bicarbonate, D-stix = dipstix/Dextrostix, sat = oxygen saturation, satting = saturating, crit = hematocrit, alk phos = alkaline phosphatase, H&H = hemoglobin and hematocrit, bilis = bilirubins, D&C = dilatation and curettage, I's & O's = inputs and outputs, Q&Q = quinine and quinidine, preemie = premature infant, trich = Trichomonas, tib-fib = tibia and fibula/ tibiofibula, fem-pop = femoropopliteal, I&D = incision and drainage or irrigation and debridement, trach = tracheostomy, trached = tracheostomy placed, XRT = radiation oncology, chemo = chemotherapy, med onc = medical oncology,rad onc = radiation oncology, pacer = pacemaker, path = pathology, vitals = vital signs, pyelo = pyelogram, admit = admission, polys = polymorphonuclear cells, eos = eosinophils, epis = epithelial cells, segs = segmental cells, sono = sonogram, maxed out = maximized, doc = doctor, detox = detoxification, angio = angiography, rehab = rehabilitation, sed rate = sedimentation rate, MVI = multivitamin, O2 sat = oxygen saturation, lymphs = lymphocyte, dip = dipstick, bleed = hemorrhage, urine osms = urine osmolality, meds = medications, desats = desaturations, sono'd = had a sonogram, cryo'd = had cryotherapy.
Discussion:

10/05/96, From Mary:
I hope others will talk to some doctors about this question and post their opinions here. This specifically relates to hospital records, since private chart notes would have a different standard, and letters yet another.

I have talked to a doctor who talks to many hospital doctors about how they want transcription done. She told me they complain about our expanding what they consider to be accepted and understood "technical terms." She thinks these terms will be added to future dictionaries. She thinks AIDS and HIV will become terms in themselves in diagnoses, not having to be expanded.

She did agree that all medications should be written out and not abbreviated, and nothing should be shortened in the diagnoses, of course. When I asked about our list of specific terms, she granted that consult (for consultation), diff (two possible meanings), cath (several possibilities) and dc (discontinued or discharged) should be expanded. All the rest, even reticking, she feels are legitimate technical terms all doctors understand.

This caused me some serious thought. If doctors all suddenly started typing their own records, they would be the only keepers of the standards of medical records, or would they? We are simply their editors, trained to be true to their style. Yet we have other standards to consider: patients, other hospital staff, insurance workers, legal considerations, other hospitals, even international hospitals. Yet they are the ones who employ us, not the insurance company, not the patient... Yet left to themselves, I can imagine medical records becoming quite corrupted by doctors! Enough yets..

I hope others will talk to doctors about this. I may have to change my Smartype and add back the words we've gathered.

The doctor did point out to me that coags could mean several things, and micro could too, as well as tox, but I told her I could often tell from the context what it meant and save the next reader having to decipher it. She said doctors usually prefer the short-hand reading, as I do the short-hand typing, especially when my keystrokes produce more characters than 1:1.

My reservations about her report are that she is only hearing from the most vocal physicians who have strong opinions about how the records read for them, who are not taking into account the bigger picture of all the uses of medical records. I hope to post this discussion on MT Daily along with the compiled list, unless someone else wants to have a web site on angelfire for this topic and be the keeper of the slang.

From Kim Randall:
All I can say is that I have the same questions after talking with probably the same person and being told the same things. Specifically, I've been told to go ahead and keep the "accepted standard recognized" abbreviations in abbreviation form because it "just reads better" to the doctors. I have no problem with doing as instructed, but my problem is that I'm still so new I don't necessarily know which abbreviations are "accepted" or "standard" or "recognized" versus those that aren't. Thus, I'm benefiting a lot from the list of slang terms we've got going here! Sorry I can't talk to any doctors about this question and offer any opinions. From Debbie Hahn:
What this doctor has said (in your posting below) sounds almost exactly what we've been told at the MT service where I work. We have been told that most of our hospital accounts (who pay our MT service, which in turn pays us) do NOT want the common, understandable abbreviations expanded.

In fact, they complain more about that than many misspellings of words, grammar errors, etc., and it's not just the "most vocal doctors". Not only do they view it as "padding" the line count they are being charged, they also find it hard to read. Of course many transcriptionists prefer to expand out as many abbreviations as possible because they make more money that way. We've even had some who have tried to set their PRD or other software to expand every single lab (serum glutamic oxaloacetic transaminase instead of SGOT, blood urea nitrogen instead of BUN, etc.). The first time I edited a report that read "the patient had a purified protein derivative placed on the right arm" I had to dig out my abbreviation book to discover it was just a PPD. It looks ridiculous to see a report with 5 occurrences of esophagogastroduodenoscopy or percutaneous endoscopic gastrostomy tube ALL spelled out when the doctor actually said PEG tube. From my personal experiences, I'm beginning to feel that the high quality standards I was trained with years ago are considered "old-fashioned" by many hospitals and doctors in today's world. I have had to put my "personal quality standards" aside and transcribe/edit according to the standards of the service who sends me my paycheck.

By the way, my #1 personal slang abbreviation gripe is "dig" -- as in "dig level" or "the patient was put on dig" (short for digoxin). I always spell that one out, because to me "dig" is to dig a hole, and the abbreviation is actually pronounced "didge or dij" yet those abbreviations don't seem to work. Another is "T'd" as in "the capsule was T'd" - I've always typed it that way but wondered if it should be "teed" (is that what they do in golf?). The other day I heard it used with "ing" on the end, throwing me into another quandry - "T-ing" ??? Then there's Y'd, V'd, etc. :)

From Christine Myers:
I think, in general, that most terms should be written out the first time with the abbreviated form in ( ) afterwards the first time; anywhere after that in the report the term could be abbreviated unless it was in the diagnosis.

I believe that certain specialists may have abbreviations widely used in their own field (Hematology: eos, seg, myelo, trigl, chol, gluc, creat, hct, hb) that could be used when corresponding with each other but when being sent to a primary care physician or such.....the terms should be spelled out. When there is a possibility of two choices for an abbreviations (ortho was a could one) then, of course, it should not be abbreviated.

The physician I work for now is almost 80 years old and very set in his ways. Neither I nor anyone else is going to tell him after all these years that his abbreviations aren't "politically correct in the transcription world" anymore! He wants what he wants and that is that. I am from the school of thought that expands all abreviations. I guess that's why he pays me by the hour!

It is really a matter of choice. If the insurance companies, HMOs, or Hospital Medical Record departments were to get involved that would be different. I know that if Medicare wants it a certain way so MD gets paid - it happens. Same with the requirements for Blue Cross/Shield and other HMOs. Perhaps it is they who should be concerned with the quality of what's in the patient's charts? There again, maybe they won't care, abbreviations would be common place and there would be less work (per line) for all of us?

From Cynthia Lewis:
This whole current thread -- plus last week's comments on commas and grammar -- plus the ongoing references to AAMT guidelines and CMT status -- make me wonder how our profession can ever be truly "standardized" -- particularly in the light of ultimately satisfying our clients/employers. When even a reference manual such as the excellent Gregg 7th Edition ends up advising us to use our own discretion at times re comma placement and verb/subject agreement, and when many of the "to hyphenate or not" decisions are left up to our own preference and common sense, it seems to me that it's hopeless to even try for across-the-board standardization.

There are differences in grammar and terms usage between every transcription school and method -- and in the end, we follow our own judgment -- and always our clients/employers preferences. Because of its complexity and constant forced-adaptation to new terms, English is not black and white EVER -- particularly when shaded by our clients' preferences. Even if there were rigid restrictions on transcription, we'd still be forced to accommodate our clients/employers.

Personally, I follow the guidelines I learned in my MT training - plus years and years of experience in writing -- plus the few preferences I've been given by my clients (all of which would be different than many other MTs' guidelines....) It truly doth boggle the mind as far as any true "standarization" goes.

From Kay, kgar41@aol.com
I can deal with most of the slang that docs use. I can deal with the made up verbs like the aforementioned "satting" and other totally absurd word forms. I just shake my head, write it out and go on. I long ago realized if these professionals could not bother to write a legible order then they could not be bothered to dictate a "legible" sentence and it was just one of my many peeves (along with whistling, singing, belching, chewing and five minute pauses). What I am finding VERY difficult to deal with is the new resident dictators who have been watching too much ER on TV and think they are Dr. Carter or Dr. Benton and dictate, 20 'migs' of Lasix or 'resps' were 40 and labored. T-max also drives me up the wall. Now, I don't know why, out of ALL the things that dictators do to annoy a transcriptionist, that these are the things that drive me CRAZY! Maybe we should start using our own slang abbreviation for "dictating physician".........."Dic doc" sounds about right to me.
From Aileen, aileenf@earthlink.net:
Well...I guess I'm just hard core/old school. It is my belief (and the way I was trained ) that transcribing using abbreviations and slang words is unprofessional and can affect patient care (all abbreviations are not universal). I train my transcriptionists in the same fashion; no abbreviations or slang unless absolutely necessary, and then in quotes. Of course, there are exceptions...lab values use pretty generalized abbreviations, and are too unwieldy expanded out, so abbrev. are preferred in this case. I guess common sense is the general rule??? Transcriptionists can use PRD or another expansion program and it shouldn't be much of a problem!

From Bambi:
Me too! I still believe a professional record should be generated, not one filled with dubious abbreviations and street slang. I would think if ultimately we are preparing a legal document, this would be the rule and not the exception.

From Mitzi Ponce:
As you know, I am doing inpatient reports on a pilot project (that seems to have finally turned into the real long-term thing!). I have had extensive contact with primarily two persons at the hospital who work with this project: one a wonderful physician and the other the "extractor" who extracts from our reports the pertinent billing/coding information and who has extensive face-to-face contact with the dictators.

The doctor who spearheaded the effort is as concerned about accuracy as we are and has supported our efforts to be correct and unambiguous. The greatest support, however, has come from the extractor. She is acutely aware of Joint Commission requirements and the fact that the records are often used by laymen, insurance folks, governmental agencies, etc., who are not conversant in doctorese.

Our docs, especially the Hem/Onc docs, are fond of dictating the likes of: crit, PRBCs, ceftaz, vanc, clinda, eryth, ifos, cytox, metho, solu, phos, mag, retics, monos, lymphs, blasts, and on and on. Especially in the area of bone marrow transplant, which as you know is such a new technology, I am very reluctant to ever lapse into doctorese. I know the difference between PRBCs (packed red blood cells) and PBSCs (peripheral blood stem cells), but I am not sure that on a quick reading by a layperson the difference in materials transfused will be immediately and definitively apparent.

The extractor and I have had a number of conversations regarding my hope that the reports be as accurate as possible. She has worked with the doctors on our behalf--explaining our position that, while we are medical language specialists, we are not doctors and we need their help and direction (i.e., they should not be ambiguous). I think, based on the changes I see in the dictation, she has represented our position well.

When transcribing these reports, I have established these guidelines:

1. No abbreviations in the diagnoses sections.
2. No abbreviations in the assessment sections.
3. No abbreviations whatsoever with multiple meanings.
4. No abbreviations without preceding instances of the full term.

So, if the doctor dictates that a child has acute lymphocytic leukemia in the diagnoses section, I feel comfortable typing ALL in the narrative summary. If, on the other hand, the doctor dictates the child has ALL in the diagnosis section and never expands that abbreviation on his/her own, I *always* type ALL throughout the report without ever expanding; and, I do this because ALL has numberous multiple meanings and, although I might make a good guess, I am not medically qualified to decide to which the physician is referring. I have to break my own rules for the sake of not assuming anything.

I guess my overriding guideline is to never assume anything! Beyond that, I always try to keep in mind that 20, 50, 100 years down the road, a physician researching these records (gosh, what a thought!) would not have a clue, perhaps, what ceftaz was. If any doctorese terms make it into the medical dictionaries, I will be happy at that point to include them in my reports. Until then....

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