Wednesday, January 14, 2009

Medical Transcription Guidelines -15


1. The trend in contemporary usage is to avoid the use of hyphens when they are not needed for clarity. Many coined words commonly used in medical reports do not appear in dictionaries, and it is up to the transcriptionist to decide whether to hyphenate them for clarity. For example, neither weightbearing nor weight-bearing (a term commonly used in orthopedic reports) appears in current English or medical dictionaries.

The hyphenated word follow-up appears as a noun and adjective in Webster's and as two words without a hyphen as a verb.

Her follow-up visit is one week from today

(follow-up as adjective)

She is scheduled for follow-up in one week.

(follow-up as noun)

She is scheduled for followup in one week.

(followup as noun)

She will follow up with the therapist in one week.

(follow up as verb)

2. Hyphens and numbers. Although the official International System of Measuring Units (SI method) recommends no punctuation of any kind be used with metric abbreviations, the use of hyphens with adjectives followed by metric measurement abbreviations is still considered optional.

Preferred: A 2 cm laceration was noted.

Optional: A 2-cm laceration was noted.

3. Hyphens and to. A hyphen may substitute for the word to in ranges, but not the word through.

4-6 weeks or 4 to 6 weeks

days 1 through 10

4. When an English unit of measure is used as a compound adjective, a hyphen is used.

The patient sustained a 3-inch wound to his distal forearm.

5. Hyphens and adjectives. Some words are hyphenated for clarity when the last letter of the first part is the same as the first letter of the second part.

nonsteroidal anti-inflammatory drug


6. Compound adjectives are routinely hyphenated when they precede the noun and not hyphenated when they follow the noun.

This patient has snow-white hair but is only 46.

The patient's hair was snow white.

7. The permanent compound adjectives all-, elect-, ex, self-, and vice- retain the hyphen whether they precede or follow the nouns they modify.

self-inflicted wound

a wound that is self-inflicted

8. In a complex modifying phrase that includes a prefix or suffix, hyphens are sometimes used to avoid ambiguity.

non-brain-injured patient

non-insulin-dependent patient

9. Hyphens and adverb-adjective combinations. Some adverb-adjective combinations are traditionally hyphenated when they appear before the noun and not hyphenated when following the noun.

The patient is a well-developed, well-nourished 57-year-old white female appearing her stated age.

The patient is well developed and well nourished.

10. Do not use a hyphen with compounds formed with adverbs ending in -ly plus a participle or adjective.

poorly developed and poorly nourished patient

highly complex symptoms

11. Hyphens and ages. Hyphenate ages when they appear before the noun they modify. Do not hyphenate ages that appear after the noun they modify.

The patient is a 36-year-old white male.

The patient is 36 years old.

This 22-year-old patient was admitted yesterday.

The patient was 22 years old.

Tip: When years is used instead of year, a hyphen is not used.

12. Hyphens and prefixes. When the prefix post (after, behind, posterior) is used as an adjective before a noun, it is connected to the root word without a hyphen.





13. The word post in the phrase status post stands alone as a compound not connected to the noun it modifies. Sometimes status is omitted but is understood.

The patient is status post closed fracture of the left leg.

The patient is post complicated hysterectomy.

14. When two prefixes combine with the same root word, the first may be hyphenated. Alternatively, the root word may be repeated for clarity.

The pre- and postoperative diagnoses were the same.

The preoperative and postoperative diagnoses were the same.

Patient had a 10- to 12-week history of symptoms.

15. The use of hyphens with mid varies. The word mid may stand alone as an adjective or combine with a root word without a hyphen.

mid and left forefoot midfoot

midline mid-1980s

16. Hyphens and suffixes. When like and most appear as suffixes, they are attached to the root word without a hyphen. If the root word ends with the same letter as the first let-ter of the suffix, hyphenate the word for clarity. If the root word has more than one syllable, hyphenation is optional.

bandlike pain yeastlike fungus

shell-like growth barrel-like chest

seizure-like or seizurelike

anterior-most or anteriormost

17. Hyphens and single letters. A hyphen is not needed to connect a single letter and noun combination, although it is acceptable to do so.

J sign Y incision

T wave T wave changes

but: C-section T-helper cell ratio

A hyphen is often used to join a single letter and an adjective or participle modifying a noun.

Y-shaped incision

18. Hyphens and clarity. A hyphen is used to clarify medical meaning when needed. In the following example, a hyphen between large and bore makes it clear that the physician is referring to the size of the bore, not the size of the needle.

A large-bore needle was selected.

(Indicates the needle had a large bore, not that the needle was large.)


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