Abbreviating diagnoses and titles

   MT Reference Style Guide  >  Medical Transcription Grammar, Usage and Style  >  Abbreviations and Acronyms  >  Basic rules for acronyms  >  Abbreviating diagnoses and titles

Critical points of information should never contain abbreviations. These include:

• diagnosis/diagnoses
• operative title
• consultative conclusion

Write out any abbreviation if it is used in the admission, discharge, preoperative or postoperative diagnosis, consultative conclusion, or operative title.

D: Operation performed: Excision of DCIS.
T: Operation performed: Excision of ductal carcinoma in situ (DCIS).

D: Diagnosis CAD.
T:
DIAGNOSIS:
Coronary artery disease (CAD).

Exception: Non-disease-entity abbreviations such as units of measure and laboratory tests.

The preference for units of measure is to abbreviate.

D: Diagnosis: DCIS measuring 2 cm in diameter.
E: Diagnosis: Ductal carcinoma in situ measuring 2 cm in diameter.

D: Discharge diagnosis is kidney failure with elevated BUN.
T: 
DISCHARGE DIAGNOSIS:
Kidney failure with elevated BUN.
NOT
Kidney failure with elevated blood urea nitrogen.

EXCEPTION: Abbreviations that are better known by their abbreviations than by the full expansion. When in doubt, transcribe in full.

D: Diagnosis is Kaposi sarcoma secondary to AIDS.
T:
DIAGNOSIS:
Kaposi sarcoma secondary to AIDS.