All Things Transcription

Abbreviations can be frustrating things, especially for medical transcription students. I have heard of many variations regarding this subject being taught by different training programs. Before we go any further, let me state that you should always remember to follow your account specifications first and to follow BOS (Book of Style) guidelines second regarding abbreviation rules if rules are not clearly spelled out in your account specifications. Once you begin working, you will find this is an often debated subject with many exceptions. You may find that your account specifications require making exceptions regarding abbreviations that are uncomfortable to you due to your recent training.

I will state that I will not under any circumstances transcribe an abbreviation that is on the JC’s (Joint Commission, formerly JCAHO) list of dangerous abbreviations. I feel that it creates too great a personal liability for me to do this. This is the official “Do Not Use” list. Having said this, I will tell you that I have had 2 situations come up where accounts wanted to use one of the abbreviations on this list. Hard to believe, I know. In the end, JC standards won out, but I still would have refused to transcribe these. As a new medical transcriptionist, you will have to make your own decision about this if you find yourself in this situation.

First and foremost, if you are currently enrolled in a medical transcription training program, I would suggest that you obtain a copy of the BOS and begin to familiarize yourself with the contents. Rules regarding abbreviations are complicated, so get a head start. While you are doing this, realize that you will come across many situations that will require you to ignore what you learn according to the desires of facilities and doctors that you work for.

Generally, you will find that some types of abbreviations are always acceptable: Metric measurements in any context, most laboratory studies (TSH, CBC, BUN, etc.) and some surgical aids (PDS sutures, GIA staplers). Again, there are always exceptions to this, refer to your account specifications.

You may also want to be aware that some children’s hospitals require expansion of abbreviations throughout the entire document so that parents can more easily read and understand the reports pertaining to their child’s medical treatments.

Another important thing to remember about abbreviations is that many of them may refer to more than one condition. Most of the time, the medical transcriptionist will be able to choose the correct expansion based on information in other parts of the report. Some dictators will automatically expand the abbreviation in the diagnosis/diagnoses portion of the examination, or if you have access to other records regarding a particular patient you can sometimes find the information there. If you are unsure of an abbreviation DO NOT expand it. You must either leave the abbreviation as is or flag the report. As in all other aspects of this profession, you MUST NOT guess! I repeat, DO NOT GUESS!

It would be great if there were better consistency regarding the dictation of abbreviations and the rules pertaining to expansion. Even when account specifications are clear, there can still be confusion. For example, your specifications state that you should always expand in the diagnosis/diagnoses section of the report. This sounds simple until you realize that some dictators will dictate this section with another heading name such as “problem list.” The doctor may clearly consider this to be the diagnosis/diagnoses section and he/she wants abbreviations expanded as he/she dictates them in expanded form. Obviously, you would go ahead and transcribe those verbatim. However, if the dictator expands all of these terms except one in that section and the account specifications state that you only expand under “diagnosis/diagnoses, do you go ahead and expand the one term that the dictator did not expand? See what I mean? You may find yourself constantly bugging QA about issues such as these until all of the exceptions are ironed out that pertain to this issue within the account specifications.

This is an almost constant debate and, until there is some consistency established in dictation methods, the debate will continue. The saving grace is that many doctors dictate consistently no matter what their chosen format is. Some of them can be very particular and will specify that they want their reports transcribed in their chosen fashion at all times with no exceptions. In a perfect world, all dictators would know what they want and be able to state it in clear and concise terms.

What it boils down to is that the subject of abbreviations will constantly come up in your career as a medical transcriptionist. It is one of those things that mean you will never be bored in this profession and you will constantly be required to learn new things. Just remember that this is what makes it fun!