Transcribing Medical Abbreviations and Acronyms Accurately
You can imagine how dangerous it could be when the abbreviation ‘MgSO4’ (Magnesium Sulfate) is transcribed as ‘MSO4’ (Morphine Sulphate) or the acronym DOA is transcribed as ‘dead on arrival’ instead of ‘date of admission’. These examples such go to show how careful medical transcriptionists should be and avoid mistakes when transcribing abbreviations and acronyms. Here are some things that need to be handled carefully:
- Guessing Meanings – It is a bad practice to guess the meaning of acronyms and abbreviations, as certain terms could have double meanings, as in the case of ‘DOA’. Instead, transcriptionists should use their reference books to look up the exact meaning of a doubtful term, relate it to the context, and memorize the rules for future use.
- Common Abbreviations and Acronyms – Certain abbreviations are acceptable as such. For instance, those used prior to or after names (Dr., Jr., Ph.D), those included in the name of an organization (Co., Ltd.), and those used to indicate time (am, pm). Transcripionists should be aware of such expressions so no time is wasted in interpreting them.
- Expanding Acronyms – If there are uncommon acronyms in the dictation, it’s better to expand them and put them in parenthesis following the relevant acronym. Expand the term when it is first used in the report and use the acronym later, and not the other way round. For example, it is incorrect to transcribe: ‘The patient had EGD this morning. The EGD (EsophagoGastroDuodenoscopy) was scheduled for yesterday.’ You should transcribe: ‘The patient had EGD (EsophagoGastroDuodenoscopy) this morning. The EGD was scheduled for yesterday.’
- Period Placement – Periods are not normally used for abbreviations or acronyms with upper case letters, though there are exceptions such as I.V. and M.I. Periods are also necessary in some abbreviations in lower case like q.i.d., q.a.d., and s.o.s. Abbreviations for metric measurements such as kg, mg, and cc do not include periods. So know the rules about period placement for accurate documentation.
- Pluralizing Abbreviations – Some abbreviations can be pluralized by using “s” at the end (for instance, WBCs (White Blood Cells)). But, if there are periods in the abbreviations, put an apostrophe after the last period and then place “s” to pluralize them (for instance, I.V.’s). The abbreviations for metric measurements remain same for singular and plural usage.
In a professional medical transcription company, transcription is handled by qualified and experienced transcriptionists who are trained in all these rules and much more. Multi-level quality control processes by editors, QA analysts and medical experts can generate documentation with accuracy levels as high as 99%.
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