Wednesday, January 21, 2009

Medical Transcription Guidelines -22

Question Marks

1. Medical transcriptionists should never, on their own accord, insert a question mark within a document to denote a word they consider to be unclear or unknown. The appropriate way to flag a document for missing words is described under Flagging Reports.

2. On some occasions, a dictator may instruct the transcriptionist to insert a question mark into a document. This is appropriate if the physician is asking a rhetorical question or asking a question of another physician. If the physician is questioning a diagnosis, it is appropriate to enclose the question mark within parentheses.

Query: Is the patient experiencing a true seizure disorder?

The question that remains, Dr. Jones, is, does Mrs. Smith know the true extent of her condition?

Dictated: DIAGNOSIS: Carcinoma in situ, stage III, question mark.

Transcribed: DIAGNOSIS: Carcinoma in situ, stage III (?).

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