Most often, physicians use abbreviations when they are dictating as it saves time. Knowledge about medical abbreviations is therefore quite critical in the medical transcription process. Only medical transcriptionists who are well-versed in these abbreviations can produce a quality report in the specified turnaround time. Knowing about commonly used abbreviations helps them figure out which one is relevant in a particular context. This is necessary to avoid misinterpretation of the abbreviations, which may lead to errors in the final report and affect patient care.
Here are some commonly used medical abbreviations which that professionals handling transcription should know about:
- A&O- alert and oriented
- BKA- below-knee amputation
- CBD- common bile duct
- CPS – Child Protective Services
- DC- discharge OR discontinue
- EKG – electrocardiogram
- FNA – fine needle aspiration
- GCS – Glasgow coma scale
- HIV – human immunodeficiency virus
- IBS- irritable bowel syndrome
- JVP- jugular venous pressure
- LLQ- left lower quadrant
- MCL- medial collateral ligament
- NICU – neonatal intensive care unit
- OT – occupational therapy
- PCP -primary care physician
- RBBB – right bundle branch block
- SFA – superficial femoral artery
- TM -tympanic membrane
- UPJ- ureteropelvic junction
- VF- ventricular fibrillation
- WDWN – well developed, well nourished
Even when the dictator mentions the whole term, a skilled transcriptionist would be able to correctly specify its abbreviation in the report. This would speed up the process and help avoid lengthy, complex sentences, improving the documentation quality, clarity and turnaround time. However, it is important to know when abbreviations are acceptable for use in medical transcription and when they are not. Knowledge about the rules and formats for lower case, upper case and mixed case abbreviations is also necessary to avoid misinterpretations and errors.
In a reliable medical transcription company, the team of professionally trained medical transcriptionists would have in-depth knowledge of clinical abbreviations and their use. In addition to this, they would constantly update their awareness and have reference materials and lists of abbreviations handy to help deliver accurate and timely documentation.
