The Basics of Laboratory Data

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Laboratory DataWhen it comes to medical transcription and editing, laboratory data has been found to cause side effects similar to those of some medications: anxiety, hair loss, difficulty sleeping, and irritability, just to name a few. These side effects often start when a student has compared the key of one report in which the labs have been separated by commas and then compares the key of another report in which the labs have been separated by groups—a comma here, a period there, seemingly willy-nilly.  Oh, the frustration!

The Book of Style for Medical Transcription, 3rd Edition suggests MTs “use commas to separate values of a single panel or test” and “use periods to separate values of unrelated…tests.” That seems to be the consensus among transcription texts across the board and is the best rule of thumb to follow in the absence of any account instructions that require punctuating according to the dictation of complete/incomplete sentences (regardless of how this affects the grouping of laboratory tests) or using a numbered list format.

When just starting out, this may seem easy enough. Short laboratory sections in simple clinic notes might include WBC, RBC, H&H, and a negative UA. As you progress, however, you’ll find that laboratory sections can become quite long and complicated with multiple blood panels, microscopic urinalysis, coagulation studies, and so on.  Memorization aside, cheat sheets can save an MT valuable time in trying to decide where to place a comma and where to place a period. As you become more familiar with common panels, punctuation will become second nature. Until then, feel free to keep these cheat sheets handy, and be sure watch for future cheat sheets as we get more into the nitty-gritty of laboratory data.

Complete Blood Count with Differential

Complete Blood Count (CBC) White Blood Count (WBC)
Red Blood Count (RBC)
Hemoglobin (Hgb)
Hematocrit (Hct)
Mean Corpuscular Volume (MCV)
Mean Corpuscular Hemoglobin (MCH)
Mean Corpuscular Hemoglobin Concentration (MCHC)
Red Cell Distribution Width (RDW)
Reticulocyte Count
Platelets
Mean Platelet Volume (MPV)
Platelet Distribution Width (PDW)
with Differential Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils



Tips

  • Hemoglobin and hematocrit is often dictated as “H&H.”
  • Reticulocyte is sometimes dictated as “retic” or “ret.”
  • While platelets is usually dictated as “platelets,” all others in the CBC list tend to be dictated in their abbreviated form.
  • In the differential list, -cytes and -phils are often omitted (ex: monocytes is dictated simply as “monos”).
  • It is not unusual for the reticulocyte count, mean platelet volume, and/or platelet distribution width to be omitted.

Basic and Comprehensive Metabolic Panels

Basic Metabolic Panel (BMP) Glucose
Calcium (Ca)
Sodium (Na)
Potassium (K)
Chloride (Cl)
Carbon Dioxide (CO2)
Blood Urea Nitrogen (BUN)
Creatinine
Comprehensive Metabolic Panel (CMP) Albumin
Total Protein (TP)
Alkaline Phosphatase
Alanine Amino Transferase (ALT)
Aspartate Amino Transferase (AST)
Bilirubin



Tips

  • A CMP is a BMP with extras: namely, liver function tests (LFTs).
  • Occasionally, electrolytes will be dictated in their abbreviated form, so if you can’t hear “potassium” but can use context to determine that a BMP or CMP is being dictated, listen for “K” instead.
  • Carbon dioxide and blood urea nitrogen are almost always dictated as “CO2” and “BUN.”
  • Keep in mind that it is C-oh-2, not C-zero-2, and that it is creatinine, not creatine (still a totally legitimate medical word, just not part of a BMP or CMP).
  • Total protein is sometimes dictated as “TP.”
  • Alkaline phosphatase and bilirubin are often dictated as shortened forms “alk phos” and “bili.”
  • Alanine amino transferase and aspartate amino transferase are almost exclusively dictated as “ALT” and “AST.” Old school dictators and older course reports will likely use SGPT and SGOT, respectively.

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