Abbreviating terms dictated in full
Do not abbreviate when a term is dictated in full except for units of measure.
D: The patient has a history of shortness of breath.
T: The patient has a history of shortness of breath.
NOT
T: The patient has a history of SOB.
Check employer/client/account specifics. It is not recommended that dosage instructions dictated in full be abbreviated unless required in the specific instructions. If unknown, transcribe in full as dictated.
D: The patient takes ibuprofen three times a day as needed for pain.
T: The patient takes ibuprofen t.i.d. p.r.n. pain.
OR
T: The patient takes ibuprofen 3 times a day as needed for pain.
