Basic Rules In Transcription

BASIC RULES IN TRANSCRIPTION AAMT STYLE GUIDE Lesson 1 American Association for Medical Transcription (AAMT) - Which represents the medical transcription profession, defines an MT as a medical language specialist who interprets and transcribes dictation by physicians and other health care professionals regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, etc. to document patient care and facilitate delivery of health care services. - Code of Ethics of AAMT was adopted on July 10, 1995. AAMT Position AAMT believes that transcribed documents are a vital and necessary component to the healthcare record. Transcription accuracy therefore should be monitored regularly to ensure quality documentation and to ensure that medical transcriptionist professionals receive timely and consistent feedback. Attention to quality should reflect an understanding that even minor errors in the record potentially can create health risks for a patient, and can diminish the credibility and perceived competence of the healthcare provider. Basic Rules in Transcription I. Spacing with Punctuation Marks a. Do not Type a Space… i. Following a period with an abbreviation (e.g. b.i.d.) ii. Following a period used as a decimal point (e.g. 5.1 mg) iii. Between quotation marks and the quoted material iv. Before or after a hyphen v. Before or after a slash vi. Before or after a dash vii. Between a number and percent sign viii. Between parentheses and the enclosed material ix. Between any word and the punctuation following it. x. Between the number and the colon used to indicate a dilute solution or ratio. xi. On either side of the colon when expressing the time of day xii. Before an apostrophe xiii. Before or after a comma used within numbers xiv. Before or after an ampersand in abbreviations, e.g. C&S xv. On either side of the colon when expressing ratios e.g. 1:1 xvi. After the closing parenthesis if another mark of punctuation follows. b. Type One Space… i. Between words ii. After a comma iii. After a semicolon iv. After a period following an initial v. After the closing parenthesis vi. On each side of the x in an expression of dimension, e.g. 4 x 4 jso,rn09

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c. Type Two spaces… i. After punctuation at the end of a sentence ii. After a colon except when expressing time or a dilution ratio II. Numbers a. Spell out WHOLE numbers zero through nine, use numerals for 10 and above. b. Use numerals when numbers are directly used with symbols. c. Use numerals when expressing ages d. If it is an approximate age, spell it out. e. Use numerals to express size and measurements. f. Use numerals for everything metric. Centimeters, millimeters, liters, etc. g. Use numerals in all expressions pertaining to drugs – this includes strength, dosage and directions. Z-PAK 2 daily on day 1, then 1 daily on days 2-5. h. Spell out and hyphenate fractions standing alone. He drank one-half a gallon of apple juice. i. Use numerals to express mixed fractions. 1 ½ years. j. Use commas only if there are 5 or more digits when expressing numbers. E.g. 10,000, 4000. k. Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration. l. Substitute a hyphen for the word “to”. He is to take 1-2 tablets of Tylenol every 4-6 hours p.r.n. m. Leave a space between numerals and measurements unless they form a compound modifier. It is 6cm below the …. It is 1200ml… A 4-cm nevus…. A 2 x 2-mm lesion…. n. Always use 0 in front of the decimal point if the number is not a whole number. 0.75 mg o. Use decimal fractions with metric measurements. 1.5 cm p. Use mixed fractions with English system measurements. 1 ½ inch q. Use numerals for: Ages, unit of measure, vital statistics, lab values and in other instances where it is important to communicate clearly the number referenced. [Example: 4 inches, 3-year-old. She has three dogs who have eight fleas each. A total of 7 basal cell carcinomas removed from his left arm. (7 for clarity)] r. Do not start a sentence using a number. Spell out the number or recast the sentence. [Example - Dictated as: 10 milligrams of Reglan was administered stat. Transcribe as: Reglan 10 mg was administered stat.] s. Exception – It is acceptable to begin a sentence with a date. Example – 2000 is going to be a prosperous year. t. Plurals – do not use an apostrophe to form plural numbers. [Example – 4 x 4s] u. She was in her 20s or twenties (this is acceptable because it is not a definite number). [Example: She was born in the 1970s] v. Series of numbers – Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction. [Example – Jeff has 1 job, 1 place of employment and 18 hours a day to do the work.] w. Cranial nerves – Preferred: Roman numerals I – XII

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x. Diabetes type 1 and type 2, not Roman numerals I and II – this was recently standardized by the American Diabetes Association. y. Cancer stages – Roman numerals; Cancer grades – Arabic numerals; In the diagnosis portion, cancer should be spelled-out; CA for cancer can be used if it is just part of a statement not a diagnosis. z. Apgar scores – Use numerals for ratings and spell out numbers relating to minutes. Rationale – to draw attention to the scores. [Example: The Apgar scores were 6 and 9 at one and five minutes. Apgar is not an acronym.] aa. Time Examples [8:30 a.m. – morning; 8:30 p.m. – evening; noon, not 12:00 noon; midnight, not 12:00 midnight or 12 o’clock or 12:00 p.m. III. Date a. Date styles are either numeric or written in words. Both are acceptable in medical transcription. Use the style as dictated by the originator. [Example: 1/1/2004; 1 Jan 2004; 1 January 2004; 01/01/2004; Jan 1, 2004; January 1, 2004] IV. Measurements a. Spell out all non-metric measurements. Feet, inches, pounds, ounces, yards, grain, dram, etc. [Exceptions: Use tsp for teaspoon; Use tbsp for tablespoon] b. Abbreviate all metric measurements. c. Use F for Fahrenheit IF accompanied by the symbol for degree. 98.6 OF. Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit. d. Use C for Celsius IF accompanied by the symbol for degree. 36OC. Spell out Celsius IF degree is spelled out. 36 degrees Celsius. e. In tables and technical documents: Use ft or ‘ for feet; Use “ for inches; Use yd for yard; Use pt for pint; Use oz for ounce; Use fl oz for fluid ounce f. List of Metric Measurements: Unit Abbreviation Centimeter(s) Cm or cm Cubic centimeter(s) cc or cm3 Cubic meter(s) m3 Deciliter(s) dL Gram(s) g Kilocalorie(s) kcal Kilogram(s) kg Kiloliter(s) kL Kilometers(s) Km Liter(s) L Meter(s) m Microgram(s) mcg Milligram(s) mg Milliliter(s) mL Millimeter(s) mm Square centimeter(s) sq cm or cm2 Square kilometer(s) sq km or km2 Square meter(s) sq m or m2 g. Example – Abbreviation most unusual units of measure when accompanied by numerals jso,rn09

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Dictated as 0.8 centimeters squared 22 milligram of mercury 3.0 liters per minute 40 millimeters per hour 8 grams percent

Transcribed as 0.8 sq cm 22 mmHg 3.0 L/min 40 mm/h 8 gm%

V. Symbols a. Spell out a symbol when used alone (with no number) b. Use symbols when they are used with numbers 1. The virgule (slash or diagonal) is used to indicate the word “per” in laboratory values and other equations or the word “over” in blood pressure (BP) readings and visual acuity. a. Example: using the virgule for “per” i. Hemoglobin 14.1 g/dL ii. Fasting blood sugar 138 mg/dL b. Example: using the virgule for “over” i. Blood pressure 110/70 mmHg in both arms ii. 20/80 right eye and 20/40 left eye (visual acuity) 2. Lowercase x is used to indicate “by” in measurements, to indicate “times” in magnification and multiplication, and to indicate “for” in other phrases. If the x can be read as the word “for,” then use the word, not “times” and not x. a. See examples on you Hillcrest Book at page 45 3. Use the numerals with a symbol or an abbreviation. When the phrase is spelled out, however, spell out the number as well. a. Examples: Deep tendon reflexes two plus (not two +) or Deep tendon reflexes 2 + (not 2 plus) 4. Both reflexes and pulses are usually graded on a scale from zero to four plus. The meanings of the different grades are as follows. a. Reflexes i. 4+ = very brisk, hyperactive; may indicate disease; often associated with clonus (alternating muscular contraction and relaxation in rapid succession) ii. 3+ = brisker than average; possibly but not necessarily indicate of disease iii. 2+ = average or normal iv. 1 + = somewhat diminished; low normal v. 0 = no response; may indicate neuropathy b. Pulses i. 0 = completely absent ii. +1 = markedly impaired iii. +2 = moderately impaired iv. +3 = slightly impaired v. +4 = normal 5. Qualitative test results are usually given using the plus and minus symbols. a. - = Negative b. +/- = very slight trace or reaction c. + = slight trace or reaction jso,rn09

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d. ++ = trace or noticeable reaction e. +++ = moderate amount of reaction f. ++++ = large amount of pronounced reaction c. Common Symbols Dictated as Transcribed as Four to five 4-5 Number 3 0 #3-0 Twenty-twenty vision 20/20 BP 120 over 80 120/80 Grade two over six 2/6 A positive A+ Three point five centimeters 3.5 cm Point five centimeters 0.5 cm VI. Capitalization a. Abbreviations when the words they represent are capitalized b. The first word following a colon if it begins complete sentence or is part of an outline entry c. Most abbreviations of English words d. The first letter of chemical elements [Example: Pb – Lead] e. The names of the days of the week, months, holidays, historic events and religious festivals f. The names of specific departments or sections in the institution only when the institution name is included g. The names of diseases that include proper nouns, eponyms or genus names. h. The trade or brand names of drugs i. A quote when it is a complete sentence j. The names of races, peoples, religions and languages. Black, as a race designation would be capitalized, however client preferences may differ. [Refer to Hillcrest book p.41, # 5: “Do not capitalize informal designations of race, i.e. white or black”] VII.Do not capitalize a. The spelled out names of the chemical elements b. The seasons of the year c. The common names of diseases d. The names of viruses unless they include a proper noun e. Genetic drug names f. The common noun following the brand name. [Example – Tylenol tablets] g. The names of medical or surgical specialities h. Designations based on skin color, like “a tall white man.” VIII. Hyphenation a. These prefixes do not require the use of a connecting hyphen in compound terms: [ante; anti; bi; co; contra; counter; de; extra; infra; inter; intra; micro; mid; non; over; pre; post; pro; pseudo; re; semi; sub; super; supra; trans; tri; ultra; un; under; weight] b. Example: overweight, preoperative, postoperative, posttraumatic, pseudogout, emicircular, sublingual, superimposed, supramammary, transvaginal, ultraviolet, underweight, weightbearing, antecubital = jso,rn09

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not ante-cubital, antithesis, bitemporal, counterproductive, defibrillated, extrapyramidal, infraumbilical, interpersonal, intracranial, microhematuria, midline, nontender, nondistended, nonfocal, nonspecific, noncontributory, noncompliance, nonicteric, nonsmall, overestimate c. Do use a hyphen with prefixes ending in “a” or “i” and a base word beginning with the same letter. [Example: anti-inflammatory] d. Do use a hyphen when compounded with the prefix self. [Example: self-administrated, self-monitored. e. 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) IX. Cancer classifications a. Stage and grade – do not capitalize either one if it does not begin a sentcence. b. Use Roman numerals for cancer stages. c. Use Arabic numerals for cancer grades. d. For clarity, use capital letters or Arabic suffixes without spaces or hyphens. i. Examples: stage 0 stage I stage IA stage II stage III stage IIIA stage IIIB stage IV grade 1 grade 2

grade 3 grade 4

X. Drug Terminology a. If dictated q.day – transcribe q.d. b. If dictated q. four hours – transcribed as q.4h. not q. 4 hours. c. 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. d. 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. e. Be aware that some drugs are commonly dictated in either milligrams or micrograms. Example – Synthroid 0.05 mg or Synthroid 50 mcg. XI. Lab Test Punctuation Guidelines a. Use commas to separate multiple related test results. Here are some examples: i. Creatinine 1.2, BUN 42, phosphorus 4.3 ii. WBC 12.4 with 72 segs, 9 lymphs. iii. 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. iv. Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100 and glucose of 80. v. Use periods to separate unrelated laboratory test results. For example, Potassium 3.7. TSH 1.0. Albumin 4.0. jso,rn09

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