Thursday, January 15, 2009

Medical Transcription Guidelines -16

Numbers

1. Metric numbers. Abbreviate metric measurements with numbers in medical reports. Abbreviations for metric measurements contain no periods and have the same form for both singular and plural.

cm centimeter, centimeters

g gram, grams

mL milliliter, milliliters

Note: The internationally accepted abbreviations for gram and milliliter (g and mL, respectively) replace the older abbreviations gm and ml.

2. Metric numbers less than one should be preceded with a zero and a decimal point for clarity, even if the zero is not dictated.

0.5 mm in diameter

3. In a series of metric measurements, the units of measure that accompany the numerals should be listed in a consistent fashion.

Dictated: 3.3 cm x 1 x 4

Transcribed: 3.3 cm x 1 cm x 4 cm OR 3.3 x 1 x 4 cm

4. Numbers and English units of measure. Standard English units of measure contain so few letters that they are usually spelled out, although abbreviations are acceptable. However, it is preferable to spell out inch and inches to avoid their being misread as the word in.

inch, inches in.

foot, feet ft.

pound, pounds lb., lbs.

ounce, ounces oz.

5. Numbers and plurals. It is not necessary to add an apostrophe when pluralizing a number, although it is acceptable to do so.

100s or 100's

4 x 4s or 4 x 4's

6. Numbers and suture sizes. Suture sizes may or may not be dictated with a number sign (#). As a general rule, transcribe as dictated. When the suture size is a single whole number, the number sign can be added for clarity.

Dictated: "Two oh Dexon"

Transcribed: 00 Dexon or 2-0 Dexon

Dictated: "Number two oh Dexon"

Transcribed: #2-0 Dexon

7. Numbers and blood pressure. The blood pressure reading contains two numbers separated by a slash mark (/). The dictator says "over" to indicate the slash. The abbreviation for the unit of measure used with blood pressure is mmHg (millimeters of mercury). Hg is the chemical symbol for mercury. There is no space between mm and Hg. The unit of measure is optional if not dictated.

Dictated: Blood pressure 120 over 80 millimeters of mercury.

Transcribed: Blood pressure 120/80 mmHg.

8. Numbers and verb forms. Use the singular form of a verb with units of measure.

Approximately 50 cc of fluid was aspirated from the peritoneal cavity.

9. Numbers and hyphens. The use of hyphens with metric measurement abbreviations is unnecessary but considered acceptable.

5 cm laceration or 5-cm laceration

10. Numbers and x. The symbol x is usually used to represent the dictated words times or by when followed by a numerical value. It is written as a lowercase letter with spaces on either side.

Dictated: Bleeding times 3 days

Transcribed: Bleeding x 3 days

Dictated: The ulcer is 2 by 4 cm in size.

Transcribed: The ulcer is 2 x 4 cm in size.

11. Numbers and lists. The dictator may number the diagnoses in a long list to be presented vertically. Sometimes a dictator will give the first several numbers and then say "number next" rather than trying to remember the next number. The transcriptionist may elect to enumerate a long list of diagnoses, even if numbers are not dictated. If there is only one diagnosis dictated, it should not be numbered.

DIAGNOSIS:

1. Chronic intravenous drug user.

2. Cellulitis, left arm.

12. Roman numerals. Roman numerals are rarely used in technical medical reports. Some notable uses, however, are the following:

cancer stages I through IV

cranial nerves II through XII

blood factors (e.g., factor VIII)

type I and type II diabetes mellitus

13. Arabic numerals. Technical medical reports generally use arabic numerals rather than words to express numbers with greater precision and accuracy.

14. Numbers and dates. Arabic numerals are used to express dates, and a comma pair is used to set off the year in the month/day/year format (November 1, 1993) within a sentence. If the date is presented in the day/month/year format (1 November 1993), a comma pair is not needed to set off the year. Although the date November 1 is pronounced November first, it is not acceptable to type November 1st, 1993.

He was admitted on November 1, 1993, and discharged on November 5, 1993.

He was admitted on 1 November 1993 and discharged on 5 November 1993.

15. Numbers and age. Arabic numerals are used for all ages. Hyphenate the age when it appears before the noun it modfies. Do not hyphenate an age that appears after the noun it modifies. Spell out terms which do not give a precise age.

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

The patient is 36 years old.

The child is a 5½-year-old female.

She is in her early twenties.

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

16. Numbers and time. Measurements of time, such as years, months, weeks, days, hours, minutes, and seconds, take arabic numerals. Exception: The number "one" can be confused with a lower-case letter L; thus, it is acceptable to spell out "one." However, if the number "one" is used in conjunction with another number, its meaning is clear and thus the numeral can be safely used.

He has had recurrent episodes of upper abdominal pain for 3 months.

She returns to see me 6 days after I first saw her in the office.

Mr. Bartley has one day left of his medication.

Mrs. Jones reports that she has been ill for 1 to 2 weeks.

17. Use a colon to express hours and minutes, but do not use a colon or a.m. and p.m. with military time.

The patient was admitted at 2:20 a.m.

The patient was admitted at 1420.

6:15 a.m. 0615 6:15 p.m. 1815

18. Use o'clock only with whole numbers to indicate position or direction.

A 2 o'clock incision was made at the umbilicus.

The needle was inserted at the 4 o'clock position.

19. Numbers and medication. Use whole numbers to express medication dosages and amounts. Exception: The number one can be confused with a lowercase letter L; thus, it is acceptable but not necessary to spell out one for clarity.

Mrs. Taylor was told to take Tavist D one q.i.d.

He is to take Phenergan with codeine 1 to 2 teaspoons t.i.d. as needed for cough.

20. Numbers and temperature. After a patient's temperature, type either a degree sign or the word degrees. It is also acceptable to type only the numerical value if the word degree is not dictated.

Temperature 98.4

Temperature 98.4°

Temperature 98.4 degrees

21. Numbers and degrees. If the physician dictates Fahrenheit or Celsius (previously known as centigrade), you may spell it out if you also spell out the word degrees. If you use the degree sign, you must abbreviate Fahrenheit as F and Celsius as C. Do not place a space between the numeral, the degree sign, and the letter F or C.

Temperature 98.4 degrees Fahrenheit or

Temperature 98.4°F

Temperature 37.5 degrees Celsius or

Temperature 37.5°C

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