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Formatting rules Formatting rules Presentation Transcript

  • Do Not Type a Space ...  following a period with an abbreviation  I.V.  following a period used as a decimal point  1.2  between quotation marks and the quoted material  “squeaky sounds” in ears  before or after a hyphen  mid-August  before or after a slash  allergies/ immunology
  •  before or after a dash  50-70%  between a number and percent sign  50%  between parentheses and the enclosed material  Irritable bowel syndrome (resolved)  between any word and the punctuation following it.  Irritable bowel syndrome, resolved.  between the number and the colon used to indicate a dilute solution or ratio.  1:2 ratio was used in his anesthesia.
  •  on either side of the colon when expressing the time of day  12:00 p.m.  before an apostrophe  The patient’s mother was present during this evaluation.  before or after a comma used within numbers  15,000  before or after an ampersand in abbreviations, e.g., C&S, T&A  on either side of the colon when expressing ratios e.g. 1:1   after the closing parenthesis if another mark of punctuation follows  Irritable bowel syndrome (resolved).
  •  between words   after a comma   after a semicolon   after a period following an initial   after the closing parenthesis   on each side of the x in an expression of dimension, e.g. 4 x 4 
  •  after punctuation at the end of a sentence   after a colon except when expressing time or a dilution ratio   after periods on itemized or enumerated data under plan/assessment. Example: 1. (2 tab spaces) Return to see me in 2 weeks.
  •  **Numbers: Spell out the numbers 1 to 9 if they are referring to an English word, or if they are referring to an approximation. Zero is generally spelled out. Numbers 10 and above should always be in figures.  Use Numerals for clarity and so they stand out from the text.  The patient was brought to the ER 1 hour after the accident.  The patient has been seen 3 times in the last month.  Height 5 foot 5 inches, weight 130 pounds.  There are exceptions to every rule.  Use your judgment and keep in mind that clarity is always the goal. You may sometimes encounter numbers in approximation, but followed by a unit of measure. This is an EXCEPTION to our rule.  D: Approximately 5 mL of blood loss.  T: Approximately 5 mL of blood loss.
  •  Approximate Numbers  There were hundreds of patients in the emergency room.  The patient is approximately six years old  The patient is approximately 60 years old.  The patient is about two months postoperative now.  The abrasion was about 1 cm in size.    Adjacent Numbers - Spell out two consecutive numbers to avoid confusion.  Take two 275 mg tablets daily.  Alor 5/500 one to two tablets q.4-6 h. p.r.n.  Three 2-inch bandages.  Use a comma between neighboring and unrelated numbers when neither can be easily expressed in words and the sentence cannot be reworded.  E.G. During the month of June 1999, 5299 prescriptions were dispensed.
  •  Fractions - According to the dictation style, spell out or use numerals for common fractions  D:  One and one-half hours ...   T:  1-1/2 hours ...  He smokes two packs and a half of cigarettes per day.  He smokes 2½ packs of cigarettes per day.  He smokes 2-1/2 packs of cigarettes per day.  (Note the use of the hyphen in mixed fractions if the subscript is not used.)  He has a 30-pack-year cigarette habit.  Use decimal fractions with the metric system.  1.5 cm  Use common fractions with the English system.  1-1/2 inch
  •  Beginning a Sentence - Do not use a numeral to begin a sentence.  Spell out the number or recast the sentence.  D:  10 mg of Reglan was administered stat.   T:  Reglan 10 mg was administered stat.  Exception - It is acceptable to begin a sentence with a year, although recasting the sentence is preferred.   Acceptable:  2000 is going to be a prosperous year.   Preferred:  The year 2000 will be prosperous.  Plurals - With single-digit numbers, use ‘s  4 x 4's  To form the plural of multiple-digit numbers, do not use an apostrophe  She was in her 30s  He was last hospitalized in the 1970s
  •  Arabic Numerals (0, 1, 3, etc.) Versus Roman Numerals - as a general rule, most numbers will be expressed in Arabic numbers unless Roman numerals are specified or preferred.  Grades are generally expressed in Arabic numbers.  grade 4/6 murmur  CIN grade 3 or  CIN-3  Developmental dysplasia, Crowe grade II (Exception - Not Crowe grade 2)
  •  Stages are generally expressed in roman numerals especially with CANCER staging, with some exceptions  stage III decubitus ulcer  ovarian cancer, FIGO stage IV  stage 3 Garden fracture (Exception - Not stage III Garden fracture)  Diabetes - The American Diabetes Association adopted the use of Arabic numbers for clarity.  Diabetes type 1  Diabetes type 2
  •  Cranial Nerves - Roman numerals are preferred.  Cranial Nerves I-XII  Apgar Scores - Use numerals for ratings and spell out numbers relating to minutes to draw attention to the scores.  Apgar is not an acronym.  The Apgar scores were 6 and 9 at one and five minutes  Zero - The number zero is spelled out when standing alone.  There was zero response to the medication.  The temperature outside dropped to zero.  Always use a zero in front of a fractional number less than zero  0.75 mg  0.25 mm
  •  Ordinals - Ordinal numbers are used to indicate order or position in a series rather than a quantity.  Ordinals are commonly spelled out, especially when the series goes higher than 10 items.  However, as with all numbers in medical reports, AAMT recommends using numerals:  1st, 2nd, 3rd, 4th, etc.  Do not use a period with ordinal numbers.  3rd rib (or third)  5th finger (or fifth)  She is to return for her 3rd (or third) visit in 2 days.  She was in her 9th or (ninth) month of pregnancy.  His return visits are scheduled for the 15th and 25th of next month.
  •  Commas - Use commas only if there are 5 or more digits when expressing numbers  4000  10,000  Time- Use numbers separated by a colon, except for even periods of time.  Do not use colons with military time.  Do not use numbers for midnight and noon.  The office closes at 8 a.m.  Her appointment was at 10 a.m.  MILITARY HOURS:  2300 hours, 1500 hours, 0830 hours  Noon, not 12 p.m. or o’clock; midnight, not 12 a.m. or o’clock
  • Transcribe dates in full.  Example: D: Blood was drawn on 10-11-05. T: Blood was drawn on October 11, 2005. D: Admitted on February twenty second T: Admitted on February 22 NOT 22nd D: Admitted on the second of February T: Admitted on the 2nd of February. D: Admitted on February the second T: Admitted on February the 2nd. D: Admitted on the second of February of this year T: Admitted on February 2, 2006 *Complete date format.  D: Admitted on February of this year.  T: Admitted on February 2006. *Delete the word of. This is assuming that the date of report is current.  D: On February of two thousand and six, she was admitted for…  T: On February 2006, she was admitted for…
  • EDUCATIONAL LEVELS: D: second grade T: 2nd grade D: fourth year in high school T: 4th year in high school
  • RANGES: D: two to fours days T: 2 to 4 days (not hyphenated) D: approximately two to four days T: approximately two to four days (approximation) D: ten to fifteen percent T: 10-15% (hyphen due to the symbol) or 10% to 15% D: ten to fifteen hertz T: 10 to 15 Hz D: L4 to S1 T: L4 through S1 D: L4 dash 5 T: L4-L5
  •  Use tsp for teaspoon   Use tbsp for tablespoon   Spell out Fahrenheit IF degree is spelled out - 98.6 degrees Fahrenheit.  Spell out Celsius IF degree is spelled out. 36 degrees Celsius.  If dictated, spell out degrees. 98.6 degrees  If degrees not dictated, do not transcribe degrees. 98.6
  •  Abbreviate most unusual units of measure when accompanied by numerals Dictated as Transcribed as 0.8 centimeters squared 0.8 sq cm 22 millimeters of mercury 22 mmHg 3.0 liters per minute 3.0 L/min 40 millimeters per hour 40 mm/h 8 grams percent 8 gm%
  •  Spell out a symbol when used alone (with no number).   Use symbols when they are used with numbers   Common Symbols 
  • Dictated as Transcribed as Four to five 4 to 5 Number 3 0 #3-0 Twenty-twenty vision 20/20 BP 120 over 80 120/80 Grade two over six 2/6 Three point five centimeters 3.5 cm Point five centimeters 0.5 cm
  • Capitalize...  Abbreviations when the words they represent are capitalized  Autism Spectrum Disorder/Pervasive Developmental Disorder (ASD/PVD)  The first word following a colon if it begins a complete sentence or is part of an outline entry  HEENT: Normocephalic  Most abbreviations of English words  I.V.  The names of the days of the week, months, holidays, historic events and religious festivals  Wednesday, February, Thanksgiving…  The names of specific departments except when it follows the word consult, ward/suite Neurology but radiology consult, pediatric ward   The trade or brand names of drugs   A quote when it is a complete sentence
  •  The seasons of the year  winter, spring, summer, fall  The common names of diseases   Generic drug names   The common noun following the brand name. Example - Tylenol tablets   Designations based on skin color, like "a tall white man." 
  •  Use hyphens when numbers are used with words as compound modifiers preceding nouns.  3.0-mm Johnson & Johnson stent  a #7-French sheath or a 7-French sheath when the word “number” is not dictated  5-cm incision  3 x 2-cm mass  13-year 2-month-old girl  The patient is 34-year-old woman, but the woman is 34 years old.
  •  Use hyphens to join some compound nouns with numbers as prefixes.  Check appropriate references for specific terms.  Use hyphens in compound numbers from 21 to 99 when they are written out.  Note:  The only time they should be written out is at the beginning of a sentence.  twenty-five  three hundred eighty-nine
  • A hyphen versus to/through  The values are accompanied by a symbol. Examples:  He is to take 1 to 2 tablets of Tylenol every 4 to 6 hours p.r.n.  Blood pressure was in the 140 to 160 range  Office hours are 1 through 4 p.m.  There is a 40-50% occlusion
  • Ante Intra semi Anti Micro sub Bi mid super Co Non supra Contra Over trans Counter Pre tri De post  ultra Extra Pro un Infra Pseudo under Inter re  weight
  •  Examples - antecubital not ante-cubital  Also Correct - antithesis, bitemporal, counterproductive, defibrillated, extrapyramidal, infraumbilical, interpersonal, intracranial, microhematuria, midline, nontender, nondistended, nonfocal, nonspecific, noncontributory, noncompliance, nonicteric, nonsmall, overestimate, overweight, preoperative, postoperative, posttraumatic, pseudogout, semicircular, sublingual, superimposed, supramammary, transvaginal, ultraviolet, underweight, weightbearing.  BUT: mid-August, mid-July…
  •  Do use a hyphen with prefixes ending in a or i and a base word beginning with the same letter. Example - anti-inflammatory.  Do use a hyphen when compounded with the prefix self.  Example - self-administered drugs, self- monitored vitals.   For Clarification - Use a hyphen after a prefix if not using a hyphen would change the meaning of the word.  Examples - re-cover (to cover again) versus recover (regain) 
  •  Stage and grade - do not capitalize either one if it does not begin a sentence.   Use Roman numerals for cancer stages.   Use Arabic numerals for cancer grades.   For clarity, use capital letters or arabic suffixes without spaces or hyphens.
  • stage 0 stage I stage IA stage II stage III stage IIIA stage IIIB stage IV grade 1 grade 2 grade 3 grade 4
  •  If dictated q.day - transcribe q.d.   If dictated q. four hours - transcribed as q.4 h. or every 4 hours not q. 4 hours  When referring to drugs including strength, dosage and directions - Use Arabic numerals only.  Example - The patient was prescribed penicillin 500 mg t.i.d. for 5 days.   If there is no whole number, always add a 0 in front of the decimal point for clarity - this is a general rule when transcribing numbers, not just medications.  Example - Dictated as Synthroid point 75 mg a day. 
  •  Transcribe as Synthroid 0.75 mg q.d.   Of note also (as seen in the example above), transcribe a day as q.d. when referring directly to the medication frequency. Twice a day for b.i.d., three times a day t.i.d. and four times a day, q.i.d.  Be aware that some drugs are commonly dictated in either milligrams or micrograms. Example -  Synthroid 0.05 mg or Synthroid 50 mcg.  Vitamins  Unless it begins a sentence, use lowercase - vitamin.  Capitalize the letter, if available use subscript for the number.  Do not leave a space between letter and number:  B12 or B12
  •  Use commas to separate multiple related test results. Here are some examples:   Creatinine 1.2, BUN 42, phosphorus 4.3.   WBC 12.4 with 72 segs, 9 lymphs.   CBC reveals an RBC count of 10.2, WBC 6.8, platelets 220,000, reticulocyte count 1 with 3 monos, 1 eos and 0 basos.   Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100 and glucose of 80.   Use periods or semicolons (as necessary) to separate unrelated laboratory test results. For example,   Potassium 3.7. TSH 1.0. Albumin 4.0.   Laboratory tests include potassium 3.7; TSH 1.0; and albumin 4.0.
  •  Names with junior or senior attached. Use a comma before and a period after the abbreviation or use neither.   Example - Jeramiah Johnson, Jr. or Jeramiah Johnson Jr   Incorrect - Jeramiah Johnson Jr.   Names with ordinals. Do not use comma between name and ordinal.   Example - Bernie Schwartz III   Incorrect - Bernie Schwartz, III   BUT IF FORMATTED AS LAST NAME, FIRST NAME: Johnson, Jeramiah, Jr. and Schwartz, Bernie, III
  •  You will encounter dictators saying “He” or “She” at the start of the report. You should edit this to become “The patient”. This is to identify the patient. After you have identified the patient, then it is alright to transcribe he, or she in the succeeding sentences. Example:  D: He is here today for a follow up for his graft. He was last seen on…  T: The patient is here to today for a follow up for his graft. He was last seen on…  Edit the obvious grammatical errors and inconsistencies in patient’s sex. If you cannot determine the actual sex of the patient, then edit the pronouns to become “the patient.”  Do not start a sentence with the word “also,” even if dictated. You should recast the sentence.
  •  Be very careful with your punctuations.  You do not need to supply articles and prepositions if not dictated, and if the sentence can stand on its own.  Itemize the diagnoses/assessment and plan if more than one was dictated.  Itemize discharge medications in a Discharge Summary.  Put a comma before the words “but” and “which” if there are more than four words after them.  Edit redundancies, but be very careful not to alter the style of the dictator.  Always transcribe the words laboratory and examination in full even if dictated as labs and exam
  •  History of Present Illness - Mainly in present tense, but mixed tense may be appropriate.   Or REASON FOR VISIT or CHIEF COMPLAINT The main reason for consultation  Then either  SUBJECTIVE: If all data under this heading contains, the patient states/denies/says/notes IF NOT USE HISTORY:  Past Medical History - Use past tense.  BUT: The patient has hypertension NOT the patient had hypertension. (since hypertension is a condition that is currently present)
  •  Allergies are typed either ALL CAPITAL LETTERS if not drugs or medication or bold font for medications.   Example - If the allergy is dictated latex, type LATEX. If dictated as allergy is Cymbalta, type Cymbalta.
  •  Transcribe in continuous paragraph format, except when the doctor numbers the medications.  Example: Penicillin 500 mg t.i.d. for 5 days, levothyroxine 0.75 mg q.d. and Lopressor 50 mg b.i.d.   Capitalize brand name medications. DO NOT capitalize generic medications.   Use Latin drug abbreviations when dictated.  Example - if dictated every day - transcribe q.d.  If dictated every four hours - transcribe every 4 hours.   Don't mix Latin and English terminology.  Example:  If dictated q. day - transcribe q.d. NOT q. day.   When referring to strength, dosage and directions - Use Arabic numerals only.   If there is no whole number, add a zero in front of the decimal point for clarity. This is a general rule when transcribing numbers, not just medications. Example:  Dictated as Synthroid point 75 milligrams a day. Transcribe Synthroid 0.75 mg q.d.
  •  Transcribe in present tense whenever applicable or as dictated.   Subheadings under review of systems should contain only the systems while under physical examination subheadings should be specific anatomical part even if dictated as system. Examples:  REVIEW OF SYSTEM:  GENITOURINARY (even if dictated as urinary tract)  PHYSICAL EXAMINATION:  SKIN (even if dictated as dermatologic)
  •  No abbreviated medical terminology.  Type the entire term or phrase.  Example - If the doctor dictates CAD, type coronary artery disease. PNA transcribe as either PERMANENT or PARTIAL NAIL AVULSION (ANALYZE THE SENTENCE)  Numbers follow the same rules for any section of the transcript.  Example - A 31-YEAR-OLD FEMALE.  5 MG.   Anatomical parts are not spelled out. MTPJ, DIPJ
  •  Use past tense:   In the past history of a report   In discharge summaries EXCEPT for the History of Present Illness and the Physical Examination sections.   When discussing expired patients   Use present tense:  To describe mostly information under physical examination  Use the correct verb tense to communicate the appropriate time of the action. Even if the dictator inadvertently changes tense during the dictation. 
  •  Fill in blanks or make notes  Consistent pronouns - he or she?   Consistent tense - was or is?   Singulars versus plurals - sclera or sclerae?  Headings - Are they labeled properly?   Sound-alike: heel vs. heals; maybe vs. may be
  •  Unnecessary awkward repetitions or redundancies  No abbreviations in diagnoses except anatomical parts when dictated as such.  Drugs correctly capitalized  Formatting, headings and indentations  Proper use of hyphens  Dates  Complete sentences  Punctuation