Tuesday, January 27, 2009

Medical Transcription Guidelines -27


1. In the transcription of medical reports, symbols are occasionally used to represent words.

2. The symbol x represents the word times and also by in measurements. Spaces are supplied before and after the x.

Dictated: bleeding times three days

Transcribed: bleeding x 3 days

Dictated: A lesion measuring 3 by 5 cm

Transcribed: A lesion measuring 3 x 5 cm

3. The ampersand (&) is used to represent the word and. There is no space before or after the ampersand.

Dictated: The patient underwent a D and C.

Transcribed: The patient underwent a D&C.

Dictated: The lungs are clear to P and A.

Transcribed: The lungs are clear to P&A.

4. The slash mark (/)-sometimes referred to as a diagonal, virgule, and stroke mark-is often used to represent the word per, especially in the expression of numerical values and units of measurement.

There were 2 to 4 WBC/hpf. white blood cells per high-power field)

She was placed on 1 cc/kg. (one cubic centimeter per kilogram)

5. The slash mark is also used to represent the word over.

Blood pressure is 140/84. (140 over 84)

The patient's vision was 20/50. (20 over 50)

6. Other commonly used symbols are the plus or positive sign (+), the minus or negative sign (-), and the percent sign ( % )

He had 3+ blood in his urine specimen.

This pregnant lady is Rh-.

FEV1 was 85% of predicted.


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