More Words / Word Board
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2/17/96, from Sue McKean, email@example.com
JCAHO on hospital abbreviation lists:
I talked to a JCAHO reviewer, an RN, who said that JCAHO no longer requires an abbreviation list, but if you are using any abbreviations then you must be able to explain how everyone knows what they stand for. A list would explain it.
From Bill Bentsen:
This question is a matter of preference. I'll quote my very favorite dictionary, Webster's 7th New Collegiate:
"-sized or -size. Having a specified size; -- used in combinations mostly either -sized or -size at choice, as full-sized or full-size, life-sized or life-size, man-sized or man-size; in some compounds more commonly -sized in combination with adjectives and -size in combination with nouns, as good-sized, also good-size; medium-sized, also medium-size; family-size, also family-sized; pocket-size, also picket-sized. Often compounds with -sized are preferred in formal writing, with -size in informal writing." So, you just take your pick as they are both correct!
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 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.
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."
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 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!
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: Alydia Kardel, firstname.lastname@example.org
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: Prgrogers@sover.net, 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.
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.
From: email@example.com (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: firstname.lastname@example.org (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.
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.