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.

Echocardiogram: Measures atrial and ventricular dilatation and size, and the position and motion of heart walls, using ultrasonic waves. Measures ejection fraction, gives information on valves, regurgitation and pressures.
Electrocardiogram: Traces electrical potentials with leads and waves, measures excitation, deflection and recovery action of muscles.

From Catherine Baxter, on “loop” and “loupe”:
A loupe used in ocular surgery is a set of glasses worn by the surgeon: “Utilizing 3X loupe magnification and an irrigating cystitome,..” Plastic surgeons will often use them when full microscopic magnification is not necessary. A lens loop is an instrument used to grasp and remove the lens.

On “affect” and “effect”
From Esther: “The above recording would be consistent with encephalopathy of diverse causes, drug (effect/affect), or as a postictal (effect/affect) following prolonged seizures.”
From Liz: I was taught to remember that EFFECT is usually a noun and AFFECT is a verb, thus an ACTION word. Remember the A for affect matches the A for action. I know there are many more in-depth explanations but the Affect/Action has worked for me since grade school, another trick taught by the St. Joe nuns in the fifties!
From Alydia: Use effect if it signifies a change and affect if it signifies an influence. In other words, your opinion might affect my decision. My decision will effect a change in policy. Of course, in psychiatry, “The patient displays a flat affect” is an easy one and does not apply to either.
effect = noun, consequence, fruit, issue, outcome, result, sequel, upshot, the way in which something acts on an object (the drying effect of strong sunlight).
effect = verb, to cause or produce, to bring into existence, as “effect a change.”
affect = impact, impress, influence, move, strike, sway.
In this light, I would choose effect for both since both the drug(s) and prolonged seizures act on or impact the encephalopathy.

Unfortunately, effect can definitely be a verb, meaning “cause” or “produce,” as in “We will effect changes in this department.” Of course, those same changes would definitely *affect* people in the department! On the use of the prefix “non”
From Gail Hall: Normally, “non” is used as a prefix and joined to the word it follows, but where it modifies a proper noun we use the hyphen as in un-American, non-Hodgkin’s, non-Q-wave. For a hyphenated phrase such as insulin-dependent diabetes, if you want to add “non” to it, you would hyphenate it as well: non-insulin-dependent diabetes. This is how Dorland’s 28th edition has it listed.
HPI’s Orthopedic/Neurology Words lists weightbearing and includes quite a few phrases. But it also says that weight-bearing is also acceptable. It lists “nonweightbearing.” So I would stick with the “joined” versions of these words. Stedman’s Orthopedic & Rehab Words lists only the “joined” versions of these words. It was interesting to note that Stedman’s followed the rule about hyphenating a prefix “non” to a hyphenated combination. They have “non” joined to words in most of their list but list “non-self-tapping screw” and “non-total-contact disorder.”

On coagulase and coagulation, from Donna Newell: Doland’s states coagulase is “a bacterial enzyme that reacts with a cofactor found in blood plasma to catalyze the formation of fibrin from fibrinogen. It is produced by Staphylococcus aureus and by Yersinia pestis.” Coagulation is the formation of blood clots, solidification of a solution into gelatinous mass or the disruption of tissue by physical means in surgery.

On bulbus and bulbous, by Bill Bentsen, 1/12/96: Bulbus is the noun. It’s used almost like the original form in Latin, also. Examples: Bulbus oculi (bulb of the eye) or eyeball; bulbus inferior venae jugularis (bulb of the inferior jugular vein), etc. Bulbous would then be the adjectival form in the same manner that callous is the adjectival form of callus. So many of these words ending in -us are almost taken directly from the original Latin. To create the adjectival forms, “like” is usually added to the root: like bulbus becomes bulbous; like callus becomes callous. The Surgical Word Book follows this same pattern. Some of the adjectival forms (bulbous) are bulbous cervix, bulbous tip of nose, etc. The noun form is bulbus or bulbus urethrae (bulb of the urethra).

From Bill Bentsen:
Cynthia, You are only about the third person I’ve ever met who even worries about slipping into the “dreaded” passive voice! It seems most people prefer to launch the passive. They must feel that by not actually taking control of action they absolve themselves of the consequence!
Even “Home Time” on PBS always has the 2 x 4’s getting installed rather than having Dean or Jo Ann actually install them! Same with hot-water heaters and so forth. I’m amazed that so many things simply happen to these objects without anyone’s having to do anything to them! Weird, huh? (Now, I wonder if this muse just got posted here, or could I have written it myself?)

From Mary Morken:
My guess has been that it is considered more modest to avoid “I” did this and that, as in operations. I suspect legal matters take their toll here–uh, I mean legal matters have taken their toll here.
From Bill Bentsen:
Perhaps so; however, so many things these days are changing to be more (or less) politically correct. I believe that’s why we’re seeing so much passive used.
Usually, the passive is appropriate only in a couple of circumstances: when a writer wishes to emphasize the receiver of the action more than the doer of the action, or when the doer isn’t important. Otherwise, the active voice usually is simpler, more vigorous or just plain clearer. The passive is very awkward is most cases.
In medical reports, probably the emphasis should be more on the object of the action: “The incision was sutured with 4-0 Vicryl.”
I see more and more writers who routinely use the passive in essay or publication writing, though. I guess they don’t wish to offend others by actually saying they did something. It’s probably better to have things just happen with no blame or responsibility associated!

From Bill Bentsen
Janie asked, “After years and years of hearing and transcribing ‘paralumbar’ and ‘normoactive,’ I now wonder if these are correct. I can’t find them in any reference books to verify.”
Medical language is a method of description using root words and combining terms, specifically prefixes and suffixes. That said, most medical terms are created by the user to describe a situation or condition; therefore, most any understood combination qualifies as a medical word.
The prefix “peri” means “around, surrounding, encircling”; the prefix “para” means “beside, near, resembling, accessory, beyond, apart from, abnormal.”
“Lumbar” is less specific for it just means “pertains to the loins,” the area between the thorax and pelvis. “Paralumbar” means near the loins; “perilumbar” means surrounding the loins. Neither terms is exact as lumbar itself isn’t too exact. I’d imagine that the doctor is using the terms interchangeably as he probably can’t tell the difference between the two too well either. You should transcribe the word which fits the context best.
“Normo” is a prefix which means normal or usual. It may be combined with most any root to create a special description: normocephalic means normally shaped head, for example. Normoactive means normally active, etc.
I’m finding some of the younger pathologists whom I transcribe for tend to use English terminology over classical terminology. They would say that the head is normally shaped. My older Japanese pathologist would simply say normocephalic. (Normocephalic isn’t in Dorland’s either; however, it is a perfectly good medical term.) I’m rather sure that the difference is that the young physicians have not studied Latin and/or Greek. As long as the resulting word is understood based on its components, the resultant combined word is just as proper as any other.

From Anton Scott Goustin,
Nef gene, protein, antigen
In general, genes taken from animal viruses are given names in lower case, such as nef, tat, myc, ras, erbB, erbA, etc. The gene names are often, but not always, italicized. The protein product of genes so named are then usually referred to with the first letter capitalized: Nef, Tat, Myc, Ras, ErbB, ErbA. The protein product is then not italicized.

Formatting Styles
From: Sue McKean,
This brings up a question that I have been wondering about for ages. I remember it at work and forget to ask when I’m home. Are acronyms allowed on physicians’ office records. How do you handle it in physician office dictation, i.e., IDDM, is stuff like this allowed? I wondered if it depends more on the physicians’ preference or the region of the country? Also do most physicians in a office situation use SOAP notes and do you abbreviate, i.e., S: O: A: and P:? Do you double space between paragraphs in a physician’s office notes or make everything in paragraph form and no double spacing to save space on the chart?.
From: Alydia Kardel,
In my experience, each physician’s office is slightly different. For one account, I use the soap format abbreviated S: O: A: P:. On another account, the headings are spelled out and in bold and on this particular account each doctor’s headings are different. No spaces between paragraphs to save on space. As far as abbreviating in the chart notes, each MD is unique in that as well. Some want lots of them while others want everything spelled out. In ER, abbreviations are okay except in the Assessment where everything is spelled out even if the doctor gives an abbreviation and I am sure this varies from hospital to hospital as well.
From:, Mary Rogers
I do transcription for the local office of an HMO and they require no abbreviations in their transcription though the doctors seem to abbreviate everything when dictating. They publish a pamphlet for their staff listing acceptable abbreviations but I think that this lists less than one-eighth of the abbreviations used when dictating. I am able to flag any abbreviations I do not know or cannot find and usually get a note back explaining what it was. They use the SOAP format with no blank lines, and they specify if they want bold or underline.
I also transcribe for a local orthopedic practice and they seem to have a whole different set of abbreviations for their specialty. I have never had any comments from them about the use or nonuse of abbreviations but prefer to type everything out for clarity. There are very few patient records that do not have copies sent out at some point and the recipient of these copies may not be a medical professional. They use a paragraph format with blank lines between and paragraph headings such as HISTORY, PHYSICAL EXAMINATION, IMPRESSION and DISPOSITION.
In our area, format seems to depend on how things were done when the practice began. As long as a consistent format is maintained throughout the record, I think format is mostly the preference of the physicians/practice.

Using Roman Numerals
Roman numerals are used for psychiatric Axis diagnoses, stage, class, cranial nerve (not spinal nerve), type, eponym, limb lead (not chest lead), phase, factor, names (Bill Smith, III) and outlining. All the rest are Arabic. Dorland’s lists gravida and para as Roman numerals, but other sources list Arabic.

Aborta or abortuses?
Dorland’s defines abortus as a fetus which is unable to survive on its own, e.g., it weighs less than 500 gm or is less than 20 weeks’ gestational age. Neither Dorland’s nor Stedman’s gives a plural form; however, usual Latin noun singulars ending in “us” form their plurals by dropping the “us” and adding an “i”, making the plural form aborti. Physicians usually say “aborta” but this has been documented only in the American Medical Association Manual of Style, p. 241, refers to “aborta” as in gravida, para, aborta (rather than abortus). Perhaps aborta is a new word that means “a woman who has an abortion,” which would be consistent with the other terms. More information needed.

10/11/95: Ringer’s lactate
From: (SDooley)
Did any of you check Drake and Drake’s Saunders Pharmaceutical Word Book for Ringer’s lactate? D&D says that the term is more correctly called Ringer’s injection, lactated, but of course we all know it as Ringer’s lactate or lactated Ringer’s. It is indeed a generic term, but it’s an eponym, named for the man who invented it probably, like Burow’s solution, so it is capitalized. See p. 390 of the 1995 edition of Drake and Drake.
Speaking of transcription couples, Ellen and Randy Drake are a classic example. They truly are co-authors of D&D. Randy started out working with Ellen as her computer nerd husband, setting up systems and stuff for their transcription service. Now he is an active participant in researching their drug book–and if there is anyone I trust for accuracy, it is Randy. If it is in Drake and Drake, you can bet it is right.

The word “mid”:
From Mary: I have been taught never to use the word “mid” alone: midportion, mid-50s. I have always attached it or typed it as “middle.”
From: (Bill Bentsen)
I get into situations in my transcription where I can’t avoid using “mid” alone: “There are lacerations in the mid and lower pleural spaces.”
I looked “mid” up in my trusty Webster’s New Collegiate Dictionary, 7th ed., and it had entries for both “mid” as a word (adjective) and for “mid-” as a prefix as follows:
Mid adj. 1. Denoting of being the middle part. 2. high and low; half-close or half-open.
Mid- Combining form denoting the middle or middle part (of the thing named), as in mid-channel, mid-continent, mid-line, mid-ocean, mid-point.
I don’t use a hyphen when using “mid-” as a prefix: midline, midaxilla, midsternal, etc., but I think that using “mid” as an adjective is okay. In fact, as above, I can’t get out of it sometimes.
From: (Toni Mercadante)
_The American Heritage Dictionary of the English Language_ notes the following: mid[superscript 1] (mid) adj. 1. Middle; central. 2. Being the part in the middle or center: in the mid Pacific. mid[superscript 2] (mid) prep. Chiefly poetic. Amid: mid smoke and flame.
mid-. Indicates a middle part, time, or location; for example, midship, midway. Note: Many compounds other than those entered here [individual listings follow] can be formed with mid-. In forming compounds mid- is normally joined to the following word or element without space or hyphen: midday. However, if the second element begins with a capital letter, it is always separated with a hyphen: mid-May. It is always acceptable to separate the elements with a hyphen to avoid possible confusion with another form; for example, mid-den (the middle of a den) as distinct from the word midden. Note that the adjective mid[superscript 1] above is a *separate word*, though, as with any adjective, it may be joined to another word with a hyphen when used as a unit modifier: in the mid Pacific, but a mid-Pacific island [emphasis added].
AAMT BOS, p. 211, indicates that mid can stand alone or serve as a prefix. Examples given are: mid to lower lung fields; mid and distal palmar creases; midday; mid-Atlantic; mid-90s.

The word “post” never stands alone, such as “postsurgery,” except for “status post.”

Three forms: a follow-up visit; he will follow up; his followup is in three weeks.
We applied a long-leg cast.
(The cast is for a long leg. Long-leg modifies cast.)
We applied a long leg cast.
(The cast for the leg is long. Long modifies leg cast.)
She is going to bear a child; she bore a child.
He bore a hole; he bored a hole.

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5/96: From Dianne Simon:
Would like to share something I wrote to help MTs understand the use of commas with modifying adjectives and in a compound sentence.
1. Commas with modifying adjectives – any word that modifies or describes a noun is an adjective:
To test whether a comma is needed between adjectives, place the word AND between the adjectives. If AND cannot be inserted between the adjectives, no comma is used. If AND can be correctly inserted, then a comma is needed.
“Eleanore is considered a brilliant, reliable, accurate accountant.” (The commas are correct because you can say brilliant AND reliable AND accurate. There is no comma after accurate, of course, because you would not say accurate AND accountant.) “Judy Marz discussed modern financial analysis with members of the committee.” (No comma is used here. You would not say modern AND financial analysis. The first adjective, modern, modifies the unit financial analysis, which consists of the second adjective plus the noun.)
2. Comma in compound sentence:
Two or more independent clauses can be joined in one sentence–a compound sentence. When they are joined by a conjunction such as AND, BUT, OR, or NOR, a comma is used before the conjunction.
Remember the four conjunctions AND, BUT, OR, and NOR. When they join two independent clauses, then each clause can stand alone–that is, the clause before the conjunction and the clause after the conjunction can stand alone as independent sentences. Therefore, to test whether a sentence is indeed a compound sentence, simply try to use the clause after the conjunction as an independent sentence. If the clause after the conjunction can be used independently, then the original sentence is a compound sentence, and a comma must be used before the conjunction.
“The damage was reported only this morning, but it will be repaired by the end of the day.” (Do you see the conjunction BUT? Now test whether what follows the conjunction is an independent clause by using it as a sentence: it will be repaired by the end of the day. Yes, it can stand alone; it is independent. Thus a comma is needed before the conjunction BUT.)
“The damage was reported only this morning but will be repaired by the end of the day.” (Again, test whether the words that follow the conjunction BUT can be used as an independent sentence: will be repaired by the end of the day. No, these words cannot stand alone because they have no subject; they are not an independent clause. Therefore, no comma is used before the conjunction in this sentence.)
To put it simply, the rule is NO SUBJECT–NO COMMA. If the words following the conjunction do not have a subject, they are not independent and no comma should procede the conjunction. Hope this helps with comma confusion!
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