(An excerpt from our work guidelines. A tiny fraction of what I have to remember. The exceptions are my favorite: unless it’s raining on a Tuesday. Or the dictator’s name is hyphenated. Or the patient is from Hungary.)
The first time an acronym is dictated in a document, expand the term and place the acronym in parentheses at the end of the term. Do not use the parentheses more than once in a document.
After an acronym has been expanded, do not expand in the remainder of the document, with exceptions as noted below:
Example: Deep venous thrombosis (DVT), congestive heart failure (CHF), irritable bowel syndrome (IBS); thereafter in the document, as DVT, CHF, and IBS, if dictated as an acronym.
Exception:Expand an acronym if it is a heading or subheading.This does not apply to HEENT, as that has become a widely recognized term.
Exception:Expand acronym when preceded by the following heading(s):
DIAGNOSIS(ES) (all types)
OPERATION OR PROCEDURE PERFORMED
Do not use parentheses in Impression/Diagnosis/ Assessment, etc., if previously utilized in document.
Note: If an acronym/abbreviation has an easily interchangeable or unclear meaning, or multiple common meanings, do not expand unless able to verify, e.g. AML. If the term can be researched and verified, expand. LABORATORY / DIAGNOSTIC DATA
Common laboratory and diagnostic tests, dictated as acronyms, do not need to be expanded.
Example: CBC, WBC, CPK, INR, CMP, BUN, CT.
Unfamiliar/uncommon and laboratory and diagnostic studies should be researched and expanded the first time in a document with parentheses:
Example: Fluorescent treponemal antibody absorption test (FTA-ABS).
Brain-type natriuretic peptide (BNP). Easily confused with BMP.
Use lowercase letters with periods for Latin abbreviations/acronyms that are related to doses and dosages. Do not expand.
Example: b.i.d., n.p.o., t.i.d., q.4 h., p.r.n.
Exception: Expand dangerous abbreviations, e.g. q.d., q.h.s., q.o.d.
Note: Do not mix latin and english, so for example, if dictated as q 4 hours, transcribe as q. 4 h.
If a term is dictated expanded, do not use abbreviation or acronym.
Exception: Metric units of measure accompanied by a numeral.
Example: The laceration measured 3 cm.
Example: The laceration extended several centimeters.
Spell out all standard (non-metric) units of measure, e.g. feet, inches, yards, pounds, ounces, joules, hertz.
Abbreviate metric units of measure used in conjunction with a numeral, e.g. cm, mm, kg, g, mg, kW, kcal.
Chemical compositions are not expanded, e.g. CO2, pCO2, pH.
Expand abbreviations according to acronym guidelines; do not use parentheses.
Example: amt is an abbreviation for amount.
Note: When a trade name contains an abbreviation, e.g., Diovan HCT, do not expand HCT; it is part of the drug name; just as Glucophage XR would never be expanded to Glucophage Extra Strength. Always check appropriate reference when determining whether or not the abbreviation is part of the trade name.
Avoid transcribing dictated slang and brief terms/phrases. Expand without parentheses.