Possibly one of the most difficult portions of just about any medical report is the laboratory data section. No two reports are identical, dictators often fly through numbers and abbreviations, and until you become profoundly familiar with a wide variety of labs, you will likely find yourself double-checking normal ranges of lab values to ensure accuracy. Also, because the context surrounding any lab test and value can be very minimal and sometimes seemingly unrelated to the chief complaint of the patient, there usually isn’t a lot of information to assist you.
Take this little adventure for example: A colleague requested some extra listening ears for a report she was reviewing. The transcription key provided by the client showed the lab test and value “IB 4.4.” Stedman’s Pathology & Lab Medicine Words listed immune body and inclusion body as possible expansions; however, neither was compatible with the value 4.4. Although not everyone’s listening ears were in agreement, IP was the popular vote, and the wild goose chase began.
The dictator’s style was notable. He dictated every term in full in the laboratory section with the exception of BUN and the stumper term. Therefore, it could be reasonably concluded that this abbreviation represented a very common laboratory term that didn’t require an MT with superpowers to decode.
Despite the context being pretty normal for the lab section—simply other labs and their values—it proved to be useful. The surrounding labs provided valuable clues as to the type of panel that had been performed and, ultimately, led to the missing term. The lab section containing the unknown abbreviation was dictated as follows:
BUN 99, creatinine 7.0, sodium 142, potassium 5.3, chloride 102, carbon dioxide 25, glucose 114 and calcium 8.9, magnesium 3.0, (___) 4.4.
It appeared the patient had a basic metabolic panel, along with some other blood work. Calcium is part of the basic metabolic panel, but magnesium is not.
Newer MTs may not be aware of some of the changes that have impacted the medical field and thus the medical report, and this is a great example of such a change. It used to be very common to hear lab results of a chemistry panel dictated as “chem” followed by a number. Chem-7 and chem-12 were at the top of the list for popularity. Over time, these tests changed a bit and are now more commonly referred to as the basic metabolic profile (BMP) and the comprehensive metabolic profile (CMP). Further, the BMP generally includes 8 labs rather than just 7, with the additional lab being calcium. Chemistry panels weren’t limited to chem-7 or chem-12; one might have had a chem-10 or chem-14 or some other chemnumber, depending on how many labs were included. The chem-10 consisted of blood urea nitrogen, creatinine, sodium, potassium, chloride, carbon dioxide (sometimes called bicarbonate), glucose, calcium, magnesium, and … ta-dah! phosphate! But wait—the abbreviation for phosphate (phosphorus) is P, not IP…or is it?
It is actually the inorganic phosphate that is measured when a phosphorus lab is ordered, but the vast majority of dictators—and others involved in the medical field—refer to it simply as phosphorus or P; for the most part, the inorganic part of the term has been dropped. Ultimately, it comes down to dictator preference, and this dictator decided to be the odd duck who prefers IP. While he may be an odd duck, the wild goose chase was finally over.
CareerStep Skills Assessment Team