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2/97, from Mary:
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.
I remember the most important as STELPPFCC ("stealth"): stage, type, eponym, limb lead, phase, psych, factor, class and cranial nerves.
Many concrete nouns, especially if derived from a foreign language, are irregular. Several plural forms of medical words are irregular: calyx, calices; arthritis, arthritides; trauma, traumata; os, ora; viscus, viscera; diagnosis, diagnoses; zygion, zygia; Streptococcus, streptococci; thorax, thoraces; foramen, foramina; femoris, femora; iris, irides; vertebra, vertebrae; bursa, bursae.
However, abstract words or conditions (or words which refer to conditions) are usually pluralized simply by adding "s": paresthesia, paresthesias; arthralgia, arthralgias; phobia, phobias.
from Bill Bentsen:
Either way is correct -- depending on the pronunciation your desire. From Gregg Reference Manual:
"To form the possessive of a singular noun that ends in an "s" sound, be guided by the way you pronounce the word:
a. If a new syllable is formed in the pronounciation of the possessive, add an apostrophe plus "s" to the noun:
your boss's approval, the witness's reply, Congress's intention, my coach's training regimen, Paris's boulevards, St Louis's airport, Mr. Morris's plane tickets, Miss Knox's decision, Ms. Lopez's application, Mr. Marsh's office, Dallas's business district, Phoenix's suburbs.
If the addition of an extra syllable would make a word ending in an "s" hard to pronounce, add the apostrophe only.
Mrs. Phillips' request, Jesus' parables, Mr. Hastings' proposal, Moses' flight from Egypt, the Burroughs' condominium,New Orleans' restaurants, Los Angeles' freeways, for goodness' sake
Individual differences in pronunciation will affect the way some of these possessives are written. For example, if you pronounce the possessive form of Perkins as two syllables, you will write Mr. Perkins' kindness; if you pronounce the possessive of Perkins as three syllables, you will write Mr. Perkins's kindness.
Some people say, that's redundant! Well, I think of it like a hallway between walls and at the ends or near the ends there are doors that go into rooms (the sinuses). That really untechnical, but that helps me understand how there can be "meatus" and "ostia" in the same area.
The combination of the passages between the nasal turbinates and the openings from the sinuses is called the "ostiomeatal complex." Believe it or not, the scope is small enough so they can look up in there and take pictures. They can see if there is blockage from such things as polyps or just plain swelling of the turbinates. Of course, they also notice if the nasal septum is crooked and causing problems.
Depending on what is causing the openings from the sinuses to be blocked, they will treat accordingly. If there are polyps and they aren't too bad, they try medication to reduce them. If that works, fine. If not, then they can do surgery to remove the polyps. The usually use lasers these days. Once the polyps are removed, though, they have to make sure the polyps don't come back. Some people are more susceptible to developing polyps than others. If the ostia are too small, they can do what they call an "ostiomeatal expansion" to increase the size so that the mucus can get out. There is normally drainage from the sinuses, and when that gets blocked for any reason, you have problems.
That's where I went to get re-count and re-place rules for re words, mid words and nonwords for ST. They are really nice, and they will give you all the rules and rationale for why they say what they say.
I was also told many years ago (about 12) to use CVA for cerebrovascular accident and c.v.a. for costovertebral angle. I was telling other transcriptionists this "rule" also until I actually looked it up one day about a year ago. All the references listed CVA as an abbrev for both and did not list cva or c.v.a. at all. Nobody had ever questioned my using it, but I did switch to using CVA for both, since that seemed to be what most MTs were using.
From Bill Bentsen:
1. _Gregg Reference Manual_: "As a general rule, use a comma after all introductory prepositional or adverbial phrases. A comma may be omitted after a short prepositional or adverbial phrase if (1) the phrase does not contain a verb form, (2) the phrase is not a transitional expression or an independent comment, or (3) there is no sacrifice in clarity or desired emphasis. (Many writers USE A COMMA AFTER ALL INTRODUCTORY PREPOSITIONAL PHRASES to avoid analyzing each situation.)"
2. _The Chicago Manual of Style_: "The comma is usually omitted after short introductory adverbial or prepositional phrases unless misreading is likely."
3. _Harbrace College Handbook_: "Introductory elements such as adverb clauses, long phrases, transitional expressions, and interjections are usually set off by commas. Many writers omit the comma after short introductory clauses, and sometimes after longer ones, when the omission does not make for difficult reading."
4. _The New York Times, Manual of Style and Usage_: " Introductory phrases should be separated from the sentence by a comma. Some writers tend to disregard commas when the phrase is short; however, standard grammar still relies on the use of the comma."
5. _Medical Transcription Guide, Dos and Don'ts_: "Do omit the comma after a brief (less than five words) introductory element if clarity is not sacrificed."
So, take your pick. Personally, I always separate the introductory prepositional or adverbial phrases with a comma. The sentence looks naked without it. I don't believe that there can be a consensus on this topic -- so, do what appeals to you!
Also, the manual further directs to use commas to set off independent comments (nonessential words or phrases that express the writer's attitude toward the meaning of the sentence). Examples are: unfortunately, ideally, actually apparently, if necessary, strictly speaking..... It also indicates that such terms modify the meaning of the entire sentence rather than a particular word in the sentence.
9/9/96, from Bambi Geist:
I've certainly noticed the trend, although have not received any "formal" instruction regarding it. Here is the rule I follow: If the patient's name has been spelled or I have written confirmation of it, then when the doctor dictates the name he gets it. However, if I do not have written confirmation or verbal spelling, in the document, no matter what he says, he gets "the patient".
In an effort to provide an accurate record, I do not think we should put the patient's name in the actual document unless we have written or verbal spelling. I think, as a patient, I'd rather see me referred to as "the patient" than Mrs. Guest.
8/30/96, from Bill Bentsen:
One of my doctors always refers to the patient as "Mr. Brown" or "Ms. Jones" or whatever, throughout the report. Another refers to the patient by name at the beginning of the report, then uses "the patient" after that. My medical examiners ALWAYS refer to the body by name, first stating that the autopsy is performed on the body of whomever, then always referring to the body by its name. It seems to me that reports in general are becoming warmer in tone, perhaps to make them more personal.
I was taught by my former employer to never use a patient's name in the main body of a report--something to do with legal ramifications should the report fall into the wrong hands. I believe at one point even the hospitals wanted it this way; I continue the practice, but can't say I like the looks of it.
I was also taught by 3 different hospitals to use "the patient" in the body of the report instead of the patient's name. I believe this must be a rule that is changing because patients are reading their own records now. Hope we get other confirmation. I'm adjusting!
From Janie Gilbert:
I'm with you...whenever the doctor dictates the patient's name, I have always put "the patient" but I have noticed that more and more doctors are using the actual patient's name. I am concerned about typing the patient's name in the report for the reason that if it has been misspelled (by the doctor), then it's more work for the proofreader to go in and correct the report. You bring up an interesting point...years ago, it was unique to hear the doctor dictate the patient's name in a report, now it appears to be more common.
From Linda Tomsha:
I have noticed the same thing. In the past I was asked to remove any occurrence of the patient's name in the report except for the demographic information in the header. In addition to the reasons you cited, we were told it was so that the reports could be used for teaching purposes. Now it seems more common to leave the information in. Another reason for clients to make sure they provide us with patient lists!
8/30/96, from Kay in Tennessee:
I do some consultation work with lawyers on malpractice cases from time to time and from a strictly legal standpoint, to name or not to name really has no LEGAL implication in court. However, hospitals and institutions DO differ on their policy and if a document is out of line with hospital policy or office policy, that CAN make a difference. (did that make sense?) It is usually safe to type exactly what the doc says UNLESS that goes against institution policy. From Peggy LaChance:
I've seen this both ways. I believe I read in an AAMT publication somewhere -- but can't put my hands on it right now -- that it was inadvisable to include the patient name anywhere in the body of a report. This eliminates having to search for names and obliterate them if the material is released.
I've also seen a "rule" which has the dictating physician deliberately include the patient's full name in the first sentence of the body of the report in addition to having dictated it any place else. This helps in eliminating mis-identified reports, such as occur when the patient name is located in a header or footer and can migrate to another report. Having worked in a place which had not-very-reliable macros to set up reports, I can attest to the value of including the patient name in the report itself.
Obviously, there are two ways of looking at the issue. Reminds me of the breaking-paragraphs/sentences-at-end-of-page issue. In that one, some people swear that there is some rule or the other which prohibits a paragraph (no matter how long it is) from being broken between pages. In another version of this "rule", it is a sentence which can't be broken between pages. This is always presented as some sort of "legal" requirement -- but the only "legal" reference I've been able to come up with is a sort of chain-of-custody type argument, in which you ALWAYS break a page in the middle of a sentence, because that provides a clear demonstration that no intervening material has been omitted. (If one page ends with one paragraph and begins with another, any amount of material could be missing or the pages out-of-order, and you'd have no way to tell. If you have to go to the next page to read the rest of the sentence, though, it's immediately clear if anything is amiss.)
From Bill Bentsen: Yes, it is. The verb "was" is the past tense of the "to be" verb. Several verbs which are "linking verbs," including the "to be" verb, require a nominative (I) rather than an object (me) in the complement; therefore, you are correct to keep the complement of the verb in the nominative case! This is the same construction as "This is she," or "This is he."
Use "an" before MRI because MRI is pronounced with a vowel sound -- "em." Also, use "an" before the following words because of the vowel or vowel sound:
an ABG report, an ERCP, an FTA, an HMO, an IRS audit, an LFT report, an MI, an NCVS, an OB/GYN physician, an Rh- mother, an SMA-7, an x-ray. Cited: The Gregg Reference-Manual, 7th ed., William A. Sabin, 1992.
STEPS TO COPY/PRINT SUFFIX ENDINGS:
EXAMPLE: ECTOMY produced 11 screens of words with that suffix. Each screen was separately "lifted" into PRD and stored, then the 11 screens, each coded with a PRD short form (e1, e2, e3....e11) were all entered into a WP5.1 document. I simply created a 12th PDR entry with all the first 11 codes entered, and the nesting feature of PRD then instantly put all 11 screens into the WP document which I then saved as a text file after a minor amount of formatting. The results are the following:
abdominohysterectomy acetabulectomy acromionectomy adenectomy adenohypophysectomy adenoidectomy adenomectomy adenotonsillectomy adipectomy adnexectomy adrenalectomy alveolectomy amygdalectomy aneurectomy aneurysmectomy angiectomy angioneurectomy annexectomy antrectomy antroduodenectomy aortectomy apicectomy apicoectomy aponeurectomy appendectomy appendicectomy arterectomy arteriectomy arteriosympathectomy arthrectomy arytenoidectomy astragalectomy autonephrectomy autosplenectomy blepharectomy blepharosphincterectomy bunionectomy bursectomy calicectomy caliectomy calvarectomy calycectomy canthectomy capsulectomy cardiectomy carpectomy cecectomy celiectomy celiohysterectomy celiomyomectomy celiosalpingectomy cervicectomy cheilectomy chemopallidectomy chemopallidothalamectomy chemothalamectomy chilectomy cholecystectomy choledochectomy chondrectomy chordectomy cicatrectomy ciliectomy cingulectomy cirsectomy claviculectomy clitorectomy clitoridectomy coccygectomy colectomy colliculectomy coloproctectomy colpectomy colpohysterectomy colpomyomectomy condylectomy cordectomy corectomy coronoidectomy corticectomy costectomy costotransversectomy craniectomy cricoidectomy cryohypophysectomy cryopallidectomy cryoprostatectomy cryopulvinectomy cryothalamectomy cryptectomy cryptorchidectomy cyclectomy cystectomy cysticolithectomy cystolithectomy cystourethrectomy dacryoadenectomy dacryocystectomy deferentectomy dentatectomy dermoidectomy diaphysectomy discectomy discoidectomy diskectomy diverticulectomy duodenectomy duodenopancreatectomy electrocholecystectomy embolectomy embryectomy endarterectomy endometrectomy enterectomy enterocolectomy epicardiectomy epicondylectomy epididymectomy epididymidectomy epididymodeferentectomy epididymovasectomy epiglottectomy epiglottidectomy epinephrectomy epiploectomy epoophorectomy esophagectomy esophagogastrectomy esophagolaryngectomy esquillectomy ethmoidectomy exostectomy exostosectomy facetectomy fasciectomy fibroidectomy fibromectomy fibromyectomy fibromyomectomy fimbriectomy fissurectomy fistulectomy foraminectomy frenectomy fundectomy fundusectomy gangliectomy ganglionectomy gangliosympathectomy gasserectomy gastrectomy gastroduodenectomy gastropylorectomy gingivectomy glomectomy glossectomy gonadectomy gonangiectomy gyrectomy hemicolectomy hemicorporectomy hemicraniectomy hemigastrectomy hemiglossectomy hemihepatectomy hemilaminectomy hemilaryngectomy hemimandibulectomy hemimaxillectomy heminephrectomy heminephroureterectomy hemipelvectomy hemiphalangectomy hemipylorectomy hemispherectomy hemistrumectomy hemithyroidectomy hemorrhoidectomy histonectomy hydrocelectomy hymenectomy hypophysectomy hysterectomy hysterocolpectomy hysteromyomectomy hysterosalpingectomy hysterotrachelectomy ileocecectomy ileectomy ileocecectomy immunosympathectomy incudectomy infarctectomy infundibulectomy iridectomy iridocorneosclerectomy rridocyclectomy iridocystectomy iritoectomy ischiectomy isthmectomy jejunectomy keratectomy kerectomy labyrinthectomy laminectomy laparectomy laparocolectomy laparocystectomy laparohysterectomy laparomyomectomy laparonephrectomy laparosalpingectomy laparosplenectomy laryngectomy laryngopharyngectomy lensectomy lentectomy lesionectomy lienectomy lingulectomy lipectomy lithectomy lobectomy logadectomy lumpectomy luteectomy lymphadenectomy lymphangiectomy lymphectomy lymphoidectomy mammectomy mandibulectomy mastectomy mastoidectomy matricectomy maxillectomy meatomastoidectomy meckelectomy medullectomy membranectomy meniscectomy mesenterectomy mesofacetectomy metacarpectomy metatarsectomy metrectomy microdiscectomy microductectomy microlaminectomy mucosectomy myectomy myomatectomy myomectomy myomohysterectomy myringectomy myringodectomy necrectomy nephrectomy nephrocapsectomy nephroureterectomy nephroureterocystectomy nesidiectomy neurectomy neuroectomy nodulectomy nymphectomy odontectomy omentectomy omentumectomy omphalectomy onychectomy oophorectomy oophorocystectomy oophorohysterectomy oophorosalpingectomy operculectomy ophthalmectomy orchectomy orchidectomy orchidoepididymectomy orchiectomy ossiculectomy ostectomy osteectomy osteoectomy otectomy ovariectomy ovariohysterectomy ovariosalpingectomy palatectomy pallidectomy pancolectomy pancreatectomy pancreaticoduodenectomy pancreatoduodenectomy pancreatolithectomy pancreectomy panhysterectomy panhysterosalpingectomy paniculectomy panniculectomy panproctocolectomy pansinusectomy papillectomy parathyroidectomy parotidectomy patellectomy penectomy pericardectomy pericardiectomy peridectomy peritectomy petrosectomy phacocystectomy phalangectomy phallectomy pharyngectomy pharyngolaryngectomy phlebectomy phrenectomy phrenicectomy phreniconeurectomy pinealectomy pituitectomy pleurectomy plexectomy pneumectomy pneumonectomy polypectomy postadenoidectomy postadrenalectomy postappendectomy postcholecystectomy postgastrectomy posthemorrhoidectomy posthysterectomy postiridectomy postlaminectomy postlobectomy postmastectomy postmyomectomy postsplenectomy preatherectomy precholecystectomy proctectomy proctocolectomy proctosigmoidectomy prostatectomy prostaticovesiculectomy prostatomyomectomy prostatoseminalvesiculectomy prostatovesiculectomy pulmonectomy pulpectomy pylorectomy pylorogastrectomy quadrantectomy radectomy radiculectomy radiectomy radiothyroidectomy radisectomy ramisectomy rectectomy rectosigmoidectomy retinectomy rhinocanthectomy rhinokyphectomy rhinommectomy rhytidectomy sacrectomy salpingectomy saphenectomy scalenectomy scapulectomy sclerectoiridectomy sclerectomy scleroticectomy scrotectomy segmentectomy septectomy sequestrectomy sialoadenectomy sigmoidectomy spermatocelectomy spermatocystectomy spermectomy sphenoethmoidectomy sphincterectomy sphyrectomy splanchnicectomy splenectomy stapedectomy staphylectomy stellectomy strumectomy suprarenalectomy suturectomy sympathectomy sympathetectomy sympathicectomy synchondrectomy syndectomy syndesmectomy synovectomy syringectomy tarsectomy tenectomy tenonectomy tenosynovectomy testectomy thalamectomy thermocauterectomy thoracectomy thrombectomy thrombintimectomy thromboembolectomy thromboendarterectomy thymectomy thymusectomy thyroidectomy thyroparathyroidectomy tonsillectomy tonsilloadenoidectomy topectomy trabeculectomy trachelectomy transversectomy trigonectomy tubectomy turbinectomy tylectomy tympanectomy tympanomastoidectomy tympanomeatomastoidectomy tympanosympathectomy typhlectomy ulectomy umbilectomy ureterectomy ureterocelectomy ureteroheminephrectomy ureteronephrectomy urethrectomy uterectomy uvulectomy vagectomy vaginalectomy vaginectomy vaginohysterectomy valvectomy valvulectomy varicocelectomy vasectomy vasovesiculectomy venectomy ventriculocordectomy vermilionectomy vertebrectomy vesiculectomy villusectomy vitrectomy vulvectomy
Please LAY the BOXES on the pallets with extreme care.
I LAID the MESSAGE right on your desk.
I HAD LAID two other NOTES there yesterday.
He IS always LAYING the BLAME on his assistants.
The dress WAS LAID in the box. [This is passive construction implying that someone LAID the dress in the box.]
Lie (principal parts: lie, lay, lain, lying) means "to recline, rest or stay" or "to take a position of rest." It refers to a person or thing as either assuming or being in a reclining position. This verb cannot take an object.
Now he LIES in bed most of the day.
The mountains LAY before us as we proceed west.
This letter HAS LAIN unanswered for two weeks.
Today's mail IS LYING on the receptionist's desk.
Test: In deciding whether to use LIE or LAY in a sentence, substitute the word place, placed or placing (as appropriate) for the word in question. If the substitute fits, the corresponding form of LAY is correct. If it doesn't, use the appropriate form of LIE.
I will (lie or lay?) down now. (You could not say, "I will PLACE down now." Therefore, write "I will LIE down now.")
I (laid or lay?) the pad on his desk. ("I PLACED the pad on his desk" works. Therefore, write "I LAID the pad.")
I (laid or lay?) awake many nights. ("I PLACED awake" doesn't work. Write "I LAY awake.")
These files have (laid or lain) untouched for some time. ("These files have PLACED untouched" doesn't work. Write "These files have LAID untouched.")
He has been (laying or lying?) down on the job. ("He has been PLACING down on the job" doesn't work. Wirte "He has been LYING down.")
NOTE: When the verb LIE means "to tell a falsehood," it has regularly formed principal parts (lie, lied, lied, lying) nad is seldom confused with the verbs just described.
The Chicago Manual of Style (14th edition, page 247) speaks of this subject. In general, I believe it's saying that "popular and lengendary" names are to be capitalized, such as East Coast, Left Bank, Bay Area (referring to San Fransisco), etc. So, while Southern California has become popularized and is correctly capitalized, southern Los Angeles County would not, as this is not popularized here in Los Angeles, or California, for that matter.
The Associated Press Style Book (1996 edition, page 62), used by newspapers, talks of "directions and regions." Paraphrasing, I believe it's saying the direction is lower case unless it's part of a proper name. Widely known sections, such as "the South, East Coast, Pacific Northwest" would be correct, but "Southern Georgia" would not. Southern California or Northern California would be correct, as it has become popularized through the years. However, southern Los Angeles County, northern Orange County, eastern Contra Costa County are not capitalized, as these are not, and have not become, popularized. The AP manual goes on to generalize, "When in doubt, use lower case."
From the context, I know hymen is correct. This is extremely clear but I couldn't document it and don't want to embarrass myself!
I'm assuming this is in an OB/GYN context. This could refer to flatus vaginalis, which is the noisy expulsion of gas from the vagina. (Gymnasts on my high school team referred to that as a "spontaneous gaseous vaginal emission," an SGVE, which made us all laugh, though I'm not sure this is the same as the term flatus vaginalis). Seems to me given the flatus vaginalis, you could have a flatulent hymen, but I can't document it either.
So, the final/discharge diagnosis and/or postoperative diagnosis should be restated as they were in the admitting or preoperative diagnosis or they should be left blank (e.g., in the case of "rule out myocardial infarction" and the transcriptionist does not know if an MI was ruled out) and then flagged for the dictator to review.
From Karen: I believe U-2 would be correct since he is probably referring to measuring from the umbilicus minus 2 cm (meaning the fundus was felt 2 cm below the umbilicus).
Regardless of your opinion on correct formation of the possessive -- and adherents of the dropped possessive don't advocate dropping the apostrophe, but dropping the entire possessive -- you still have to use the correct test, disease, or classification name.
The childhood disease is Dukes' disease, named after one Clement Dukes. The bleeding time test is Duke's test, named after W. W. Duke. The classification system is Dukes' classification, named after Cuthbert E. Dukes.
The easiest way to handle this is just like I have it above. If you follow That Trend and drop the possessive, all sorts of terrible things happen. People who like to drop the possessive tend to be those who didn't understand how to form it in the first place, so when they "drop it" they usually drop "it" and something else, as well. Besides, huge numbers of clients (the doctors) think it looks illiterate or just plain strange, and it upsets them.
The correct dropped forms are: Dukes disease (NOT Duke disease!) Duke test (NOT Dukes test!) Dukes classification (NOT Duke classification!)
To sum up, FIRST you determine which Duke/Dukes you are dealing with, THEN you either use it plain or with the possessive. There are a huge number of other eponymic goodies which must be dealt with in a similar manner.
From Pauline Alley:
This test is referred to as pulse oximetry because a little clip is placed over the tip of the finger through which the oxygen content of the blood is analyzed electronically as the blood flows through the vessels (or pulsates as they say). In these days of persons having to qualify for insurance reimbursement, it is crucial that these measurements are accurate because Medicare and other insurance companies base their reimbursements on these measurements. The "qualifying " measurement for full home oxygen reimbursement would have to be 88% oxygen saturation or below.