1. Abbreviations, acronyms, and initialisms are frequently dic-
tated in medical reports and are an integral part of medicine. When abbreviations are dictated, transcriptionists should consult their reference books for their meanings and memorize them for future use.
2. Many medical transcriptionists readily type abbreviations verbatim when dictated. Some transcriptionists prefer to translate most abbreviations and brief forms when dictated,
believing that abbreviations obscure the clarity of the med-
ical report and make it imprecise. Many facilities require the translation of abbreviations, especially when they appear in the diagnosis or impression section of a report.
In rare instances, the translation of abbreviations may cause confusion rather than achieve clarity. For example, VDRL is readily recognized as a laboratory test for syphilis and it is not necessary or desirable to translate it, even in a diagnosis or impression.
3. The first time an uncommon abbreviation is used within a report, the transcriptionist may transcribe it as dictated and translate it in parentheses following the abbreviation. The abbreviation may then be used without further translation in the report that follows.
Dictated: This patient was seen for PVH.
Transcribed: This patient was seen for PVH
(persistent viral hepatitis).
4. When an abbreviation is dictated in the diagnosis or impression, it should be translated for clarity.
Dictated: DIAGNOSIS: Status post TAH, BSO. Transcribed: DIAGNOSIS: Status post TAH, BSO
(total abdominal hysterectomy, bilateral salpingo-oophorectomy)
5. Occasionally, an abbreviation may have more than one translation. If the abbreviation the physician is using has a widely recognized meaning, and if the meaning of the abbreviation is perfectly clear within the context of the re-port, it probably does not need to be translated. However, it is usually acceptable to expand abbreviations to promote clarity of the medical document. For uncommon abbreviations, the abbreviation may be typed as dictated and the trans- lation placed in parentheses following the abbreviation.
Dictated: The patient suffers from PND, which
causes chronic sore throats.
Transcribed: The patient suffers from PND (postnasal drainage), which causes chronic sore throats.
Dictated and Transcribed:
The patient suffers from orthopnea, PND, and nocturnal dyspnea.
In the latter example, it is not necessary to translate PND because the reader will understand that PND in this context refers to paroxysmal nocturnal dyspnea, not postnasal drainage. It would be acceptable, however, to translate the abbreviation for clarity.
6. Medical abbreviations are written in several ways. The three most common include all capital letters, a combination of capital and lowercase letters, and all lowercase letters with periods. Seldom are periods used with uppercase abbreviations. Periods are generally not used with combination uppercase and lowercase abbreviations, with the exception of Ph.D.
p.o. b.i.d by mouth twice daily
q.h.s. every night at bedtime
KCl potassium chloride
CHF congestive heart failure
7. The abbreviations for intravenous and intramuscular are written without periods (IV, IM) for simplicity by many transcriptionists, or with periods (I.V., I.M.) to avoid I.V. being misread as roman numeral four (IV). References are inconsistent, at times writing them with periods and at times without. Both forms are acceptable, but the transcrip-tionist should be consistent in usage within a report.
IV, IM; I.V., I.M. (intravenous, intramuscular)
8. An acronym is a word formed from the first letters of other
words. Acronyms are initially formed with capital letters, but after they gain acceptance as words, they are some-times converted to lowercase letters and their origin as ini-
tialisms is forgotten.
AIDS (acquired immunodeficiency syndrome)
CABG ("cabbage"-coronary artery bypass graft)
ELISA (enzyme-linked immunosorbent assay)
fabere (flexion-abduction-external rotation-extension) test laser (light amplification by stimulated emission of
simkin (simulation kinetics) analysis
9. To make an abbreviation plural, simply add the letter s with no apostrophe if the abbreviation is in all capital letters. If the abbreviation (M.D., for example) ends in a period, add an apostrophe and s (M.D.'s).
A series of CBCs (complete blood counts) was ordered.
DTRs (deep tendon reflexes) were 3+ and equal
IVs (or I.V.'s) were ordered to run TKO (to keep open).
Three M.D.'s were invited to speak.
10. When abbreviations are used with numbers for medication dosage times, use periods.
q.4h. or q. 4 hr. (every 4 hours)
q.12h. or q. 12 hr. (every 12 hours)
11. An abbreviation, such as the name of a lab test, dictated at the beginning of a sentence or in the body of a report may be transcribed as dictated if its meaning is clearly understood. If abbreviations are not dictated, the transcriptionist should not supply them. Exception: metric units of mea-sure, which are routinely abbreviated.
ST depression was noted on EKG.
SGOT was elevated at 60 IU/dL.
CBC and electrolytes were within normal limits.
12. If the dictator abbreviates the title of a major heading within a report, the transcriptionist should translate the abbreviation.
Transcribed: History of Present Illness
13. Abbreviating metric measurements accompanied by nu-merals is preferred in medical reports. Abbreviations for metric measurements contain no periods and have the same form for singular and plural usage.
kg (kilogram)(s) cc (cubic centimeter)(s)
g (gram)(s) cm (centimeter)(s)
mg (milligram)(s) mEq (milliequivalent)(s)
14. Do not abbreviate a metric measurement if no specific numeral is dictated.
The scar was several centimeters in length.
15. Standard English units of measure (inch, foot, pound) are so short that they are usually spelled out, although foot and pound are correctly abbreviated ft. and lb., respectively (note the periods). The standard abbreviation for inch is in., although it is recommended that it not be used in medical reports as it is too easily confused with the preposition in. Exception: It is common to use the abbreviation for pounds (lbs.) and single and double quotation marks for feet and inches in presenting weight and height figures in medical reports.
Weight 120 lbs., height 5'2".
Affect and Effect
1. The word affect is most often used as a verb and, as such, is pronounced as though it begins with a short uh sound. The accent is on the second syllable (uh-fekt´). Affect means to change or to influence.
The combination of narcotics affected (influenced) the patient's sensorium.
The use of some drugs affects (changes) the effectiveness
2. The verb affect is often accompanied by helping verbs, i.e., was, is, shall, will, has, have. The verb endings -ed and -ing may also be added.
It is uncertain how the news of his terminal state will
affect (influence) the patient.
3. The word effect is most often used as a noun. When used as a noun, it is often preceded by the words an, the, this, these, as well as other adjectives such as positive, good, poor.
It is uncertain what effect (outcome) the news of his
terminal illness will have on the patient.
4. The noun effect is often the object of a verb. In one example below, effect is not only the object of the verb produced but is preceded by an adjective, i.e., an article and an adjec- tive. It means the outcome, result, product, sequel, or end of an action.
The combination of drugs produced an adverse effect.
The surgical procedure produced a good cosmetic effect.
5. Often, effect is used in the context of a drug's action or with names.
digitalis effect Doppler effect
placebo effect Tyndall effect
6. When used as a verb, effect is pronounced by some doc-tors as though it begins with a long e sound (ee´fekt) so that we will spell it correctly. As a verb, effect means to accomplish, to cause, to create, to do, or to execute in such a manner as to bring about a desired result.
This therapy should effect a cure.
Closure was effected (brought about) by interrupted
This regimen effected (brought about) a reversal of the patient's symptoms.
7. In summary, affect is most often used as a verb; therefore, it has verb endings (-ed, -ing), is used with helping verbs (has, is, was), and means to change or influence.
8. Effect is most often used as a noun and means the result or outcome of some action. It may be preceded by articles (a, an, the) and other adjectives (this, these, good, placebo, ill, side, negative).
9. In psychiatry, the word affect (usually pronounced "af´-fekt," with a short "a" sound and the emphasis on the first syllable) is commonly used as a noun, meaning an outward appearance of an inner emotion.
The patient demonstrated a flat affect.
This patient's affect has affected her ability to effect a normal relationship with others and work effectively but has had no effect on her ability to care for herself.
This patient's emotional state has changed her ability to achieve or accomplish a normal relationship with others and work with good results, but has had no result on her ability to care for herself.
The effects of transcribing difficult reports affect our affect to such an extent that we cannot effect transcription effectively.
The results of transcribing difficult reports influence our emotional state to such an extent that we cannot accomplish transcription with good results.
Agreement of Subject and Verb
1. A verb agrees in number with its subject (a noun or pronoun). A singular subject must be matched with a singular verb, a plural subject with a plural verb. Subject-verb agreement errors occur frequently in medical dictation, and it is the medical transcriptionist's responsibility to correct such errors.
2. The first steps in assuring subject-verb agreement are to analyze the sentence, identify the subject of the sentence, and decide if the subject is singular or plural. Then check to see if the verb agrees with the subject in number.
If dictated: The edema in both legs have not yet responded to diuretics.
Transcribe: The edema in both legs has not yet
responded to diuretics.
Note: The word legs is part of the prepositional phrase intervening between the subject (edema) and the verb.
3. When a compound subject joined by or is present, make the verb agree in number with the closest noun.
No definite adenopathy or masses were felt.
No definite masses or adenopathy was felt.
4. If a compound subject is joined by and, a plural verb is used even if the word closest to the verb is singular.
The patient's gait and station were normal.
Hemoglobin and hematocrit were 14 and 40, respectively.
1. Apostrophes are used to show possession.
The laboratory tests were ordered by Dr. Cole's office. Mrs. McElroy's condition has deteriorated significantly. Those surgical instruments are Dr. Jones's personal
Alternative: Those surgical instruments are Dr. Jones'
2. Apostrophes are used to show singular and plural possession or ownership, notably with units of time.
She is to return to see me in one month's time.
He has had a pain in the right groin of two months'
The uterus is 16 weeks' size.
3. It's is a contraction for it is; use of the apostrophe indicates that a letter has been omitted. Its is a possessive pronoun and does not use an apostrophe; the words it is cannot be substituted.
It's (it is) my opinion that she has an immune disorder. The fetus was noted to have its back to the camera on ultrasound. (Cannot substitute it is.)
4. Apostrophes are not needed when forming the plurals of abbreviations or numbers, except in abbreviations containing periods and to avoid confusion when lowercase letters or symbols are made plural.
WBCs CMTs 40s 1990s
x's and y's +'s M.D.'s
5. Avoid using an apostrophe and s with eponyms (something named for a person) when referring to surgical instruments and medical devices.
Fogarty catheter (not Fogarty's catheter)
DeBakey clamp (not DeBakey's clamp)
6. The use of the apostrophe and s with other eponyms is determined by common usage. The transcriptionist should consult a medical dictionary to determine current usage, if the dictating physician's preference is not known.
Kasai operation McBurney's incision
Apgar score McMurray's maneuver
Exception: Hyphenated eponyms do not use an apostrophe to show possession.
Abbe's operation Abbe-Estlander operation
Chiari's disease Budd-Chiari syndrome
7. Various medical dictionaries and style references often disagree with each other about whether a particular eponym should have an apostrophe and s to show possession; thus, in many instances there may be more than one acceptable style.
Homans sign Homans' sign
Cushing syndrome Cushing's syndrome
Babinski reflex Babinski's reflex
Graves disease Graves' disease
8. If a, an, or the precedes an eponym, it is not necessary to use the possessive apostrophe and s.
She was placed in the Trendelenburg position.
A McBurney incision was made in the right lower
The Bassini hernia repair was accomplished without
Brief Forms and Medical Slang
1. Brief forms are shortened forms of legitimate words that can be documented in a reputable dictionary or have come into acceptance through usage. A slang term is either not listed in a dictionary or is designated as slang.
2. Medical slang should be avoided in medical documents for several reasons. A slang term may be obscure and might not clearly or accurately convey the intended meaning. Additionally, a slang term may be open to varied interpre-tations by different readers of the record, particularly obvi-ous when a health record is subpoenaed by legal process.
3. Slang terms used disparagingly to refer to patients should be avoided. Physicians do not intend for offensive or offcolor remarks to be entered into a patient's health record.
4. Brief forms can be easily confused with medical slang. Physicians commonly use medical slang when discussing a patient's condition, but that does not mean the same slang term is acceptable in the medical report transcript.
5. Following are some terms that are currently deemed acceptable, unacceptable, or equivocal. A good rule to remember is, "When in doubt, write it out."
Acceptable Brief Forms
ab, AB abortion
bands band neutrophils
Pap smear Papanicolaou smear
polys polymorphonuclear leukocytes
pro time prothrombin time
sed rate sedimentation rate
segs segmented neutrophils
Unacceptable Medical Slang
cath, cath'd catheter, catheterized
coags coagulation studies
DC, DC'd discharge(d), discontinue(d)
dig ("dij") digitalis
fib fibula, fibrillation
H. flu H. (Haemophilus) influenzae
H&H hemoglobin and hematocrit
Metz Metzenbaum scissors
romied verb form of ROMI (rule out MI)
tabby therapeutic abortion
V fib ventricular fibrillation
V tach ventricular tachycardia
Equivocal Medical Slang/Abbreviations
BP blood pressure
1. Capitalize all letters in main headings, unless instructed otherwise. Subheadings are sometimes presented in all cap-itals in a vertical arrangement. Alternatively, only the initial letter of a subheading is capitalized.
VITAL SIGNS: Blood pressure 120/80, temperature
CHEST: Clear to auscultation.
HEART: Regular rate and rhythm.
Vital signs: Blood pressure 120/80, temperature normal. Chest: Clear to auscultation.
Heart: Regular rate and rhythm.
2. Capitalize the first word following a colon in a heading or subheading.
DIAGNOSIS: Lung cancer, metastatic.
SPLEEN: The spleen is enlarged.
Spleen: Spleen is enlarged.
3. Do not capitalize the names of the seasons.
She is scheduled for follow-up in the spring.
4. Do not capitalize the first letter of points on a compass unless referring to geographical regions or for clarity.
The clinic is east of the hospital.
The patient is from the Southeast.
The patient is on 3 East.
5. Do not capitalize diseases or anatomic landmarks unless they are eponyms (named for a person).
chronic obstructive pulmonary disease
latissimus dorsi muscle
sphincter of Oddi
space of Retzius
6. It is not necessary to capitalize the names of departments within a medical facility; however, it is acceptable to do so when needed for clarity.
radiology department operating room
physical therapy emergency department
The patient will be seen by Anesthesia in the morning.
7. Capitalize the trade name of a drug but not the generic name.
8. Do not capitalize nouns associated with the trade name of a drug.
Tylenol elixir Demerol injection
9. Capitalize the person's name that is the basis of an eponym.
10. When the eponym is made into an adjective or verb, do not capitalize it.
11. Capitalize the genus but not the species name for bacteria. When the genus is abbreviated, capitalize the one-letter abbreviation. The genus and species are correctly typeset in italics in books and journals. In typed medical reports it is proper to italicize or underscore them, but it is also acceptable to type them in plain face.
Escherichia coli E. coli
Haemophilus influenzae H. influenzae
12. When a genus name is made into an adjective or plural, do not capitalize it.
Mycoplasma (genus) mycoplasmal (adj.)
Streptococcus (genus) streptococcal (adj.)
13. Names of viruses are not capitalized unless named for a person. Note: Herpesvirus is one word.
herpes Epstein-Barr virus
14. Capitalize titles such as M.D. (or MD), R.N. (or RN), CMT, CMA, ART, RRA, and academic degrees such as BA, M.Ed., Ph.D., and so on. Doctor is correctly abbreviated as Dr. When transcribing a medical doctor's name, do not use both Dr. and M.D. Do not capitalize the name of a physician specialist (or other specialist) or the medical specialty.
physical therapy, physical therapist
15. Capitalize a person's race, ethnic or national origin, but not skin color.
Caucasian female white female
African-American male black female
Oriental female Hispanic male
16. Do not capitalize words that denote categories or classi-fications.
grade 1/6 murmur stage I
type IIb hyperlipidemia Bruce protocol
17. Do not capitalize the terms gravida or para. The brief form ab (abortion) may be lowercase or capitalized (AB).
gravida 3, pare 2, ab 1
18. The patient's allergies may be typed in all capitals within the report to make them stand out. This is particularly helpful with a drug allergy so that the patient will not be given that drug inadvertently.
ALLERGIES to PENICILLIN and SULFA DRUGS
19. Greek letter names are not capitalized.
alpha-chymotrypsin alpha-fetoprotein lab test
beta blocker drugs beta-lactamase
1. Use a colon after a heading, followed by a space. (Some prefer two spaces after a colon or period.)
CHIEF COMPLAINT: Left-sided paralysis.
2. When a complete sentence ends with the words as follows or the following, use a colon and then continue with the list or series that follows.
His symptoms include all of the following: dyspnea on exertion, fatigue, and productive cough.
3. Do not use a colon between a verb and a list that follows.
His symptoms include exertion, fatigue, and productive cough.
4. Use a colon to express a ratio (a mathematical expression showing the relationship of one part to another).
Xylocaine 1:100,000 was instilled. (Indicates that there is one part Xylocaine to 100,000 parts solution.)
A/G ratio was 2.1.
Albumin-globulin ratio was 2.1.
Note: Only the ratio value uses the colon; the actual lab- oratory test uses a slash mark or hyphen.
5. Use a colon to express hours and minutes, but do not use a colon with military time.
The patient was admitted to the emergency department at 2:20 a.m.
The patient was admitted at 1420 hours.
1. Comma misuse. The comma is probably the most misused punctuation mark in the written English language. Misuse includes inserting too many commas, too few, or using them inappropriately so that the meaning of a sentence is unclear or may be misconstrued. In medicine, this can have serious consequences by changing medical meaning.
2. Commas and compound sentences. A compound sentence consists of two independent clauses joined most commonly by the conjunctions and, but, for, or, nor. If the two independent clauses-each a complete sentence-are short (only about four or five words long), a comma is not needed to separate them but may be used. If each independent clause is longer, a comma is generally used.
Before inserting a comma, check to be sure that the sec-ond part of the sentence is really an independent clause. Sometimes the second part of the sentence contains only a verb that agrees with the subject in the first part of the sentence. In that case, do not insert a comma because a comma should never separate a subject from its verb.
The patient is having chest pain, but she denies diaphoresis or dyspnea.
Both parts of the sentence are independent clauses and contain a subject and a verb. A comma is optional because the clauses are short.
The patient is having chest pain but denies diaphoresis and dyspnea.
No comma should be used because patient is the subject and the sentence has a compound verb, is having and denies.
3. Commas and adjectives. Commas are used with adjectives and nouns in a series according to the a, b, and c rule or the a, b and c rule. The use of the final comma before the word and or or in any list is optional if it does not distort medical meaning.
I have ordered a CBC, BUN, and creatinine.
I have ordered a CBC, BUN and creatinine.
4. Commas and adjectives in a series. Use a comma to separate adjectives or nouns in a series, but do not put a comma between the last adjective in a series and the noun that follows it.
The patient is a 60-year-old, frail, disoriented female.
5. Race. When the patient's race is given, consider it to be part of the noun and not an adjective.
The patient is a 70-year-old, frail, disoriented Caucasian female.
Tip: If you can substitute "and" for the comma in an adjective series, and the sentence sounds natural, it is usually safe to use the comma.
The patient was wearing a sleeveless black vest.
(No comma after sleeveless, because it sounds unnatural to say, "The patient was wearing a sleeveless and black vest.")
6. Commas and titles. Use a comma pair to set off a degree or title.
Marion Bartley, M.D., has agreed to see the patient in the emergency department.
Pamela K. Wear, RRA, and Vera Pyle, CMT, presented a seminar on confidentiality of health records.
7. Commas and appositives. Use a comma pair with an ap-positive if it provides information that is not essential to understanding the meaning of the sentence. (Note: An appositive is a phrase that immediately follows another word to identify or explain it.) If the appositive provides information that is essential to understanding the meaning of the sentence, do not use commas. Titles such as M.D. and CMT are treated as nonessential appositives, and thus a comma pair is used.
Dr. Dianna McElroy, the head of the department of
cardiology, will provide us with a detailed follow-up evaluation on this patient.
Patient Ima N. Payne has asked me to write this letter to inquire about insurance coverage of this surgical
Linda Campbell, CMT, transcribed that particular report. The patient was referred to Carl Steward, M.D., for
consultation and was asked to return to see me immediately after that visit.
8. Commas and diagnoses. Use a comma when the disease entity or condition is followed by its location in the body or when the term is followed by an adjective describing it.
Deep venous thrombosis, right leg.
9. Commas and introductory phrases and clauses. Use a comma to separate an introductory adverbial clause or prepositional phrase from the main independent clause of the sentence. If the introductory phrase or clause is short (less than five words), you can omit the comma if the meaning is clear.
When he experiences his typical chest pain, he always
takes nitroglycerin sublingually.
On this occasion the patient is pleasant and cheerful.
10. Commas and introductory transitional words/phrases. Commas are often used to separate an introductory transitional word or phrase from the rest of the sentence. However, there is precedent in current usage for omitting the comma.
As a result, we felt that the patient was not a candidate for cardiac bypass.
As a result we felt that the patient was not a candidate for cardiac bypass.
Consequently, it was decided not to admit Mr. Smith at
Consequently it was decided not to admit Mr. Smith at this time.
Otherwise, he will return to see me in a month.
Otherwise he will return to see me in a month.
11. Commas and semicolons. Use a comma to separate internal elements in sections that are already separated by semicolons.
HEART: Regular rate and rhythm; no murmur, gallop, or rub; S1 and S2 normal.
12. Commas with however. If the word however is in the middle of an independent clause, place commas around it.
The patient was, however, very tired.
The patient was very tired, however, complaining of weak- ness and fatigue.
13. If the word however separates two independent clauses, place a semicolon before however and a comma after it.
The patient was very tired; however, he did not complain of weakness.
14. Comma pair with phrases. Use a comma pair to set off nonessential phrases within a sentence. Omitting one of the commas in a comma pair is termed a comma fault.
Her condition, in my opinion, is critical.
15. Comma pair in dates. Use a comma pair to set off the year within a sentence when the date is presented in the month/day/year format. When the date is presented in the day/month/year format, a comma is not needed. Do not use a comma pair when only the month and year are given.
The patient is scheduled for surgery on June 15, 1995, at Valley General Hospital.
The patient is scheduled for surgery on 15 June 1995 at
Valley General Hospital.
She had open heart surgery in June 1995 at Valley General Hospital.
1. Contractions are a completely acceptable part of speech and are in no way considered slang or inappropriate. They are also an integral part of dictated medical reports, which are basically informal and filled with brief forms, abbreviations, clipped sentences, and numerous shortcuts. Contractions are neither obscure nor do they take anything away from the transcribed medical document. Thus, in these transcript keys, contractions are transcribed verbatim when they are dictated. Contractions are not provided when they are not dictated.
2. Some transcriptionists recommend expanding all dictated contractions, believing that the use of contractions makes the medical report appear too casual or informal. The transcriptionist on the job would follow the facility's guidelines for use of contractions.
1. Do not confuse a dash with a hyphen. A hyphen differs in both use and appearance from a dash. Dashes are used to give greater emphasis, to explain a statement, to replace a comma or comma pair, or to set off a parenthetical statement.
This 65-year-old African-American female did not return to the office for follow-up until today-in spite of my warnings to the contrary-and the squamous cell carcinoma on the nose has likely metastasized in the interim.
2. A hyphen (-) is shorter than a dash (-).
1. Every dictator has at one time or another misspoken and said something like, "The patient smokes two beers a day and drinks two packs," or refers to the surgery on the left leg in one paragraph and the right in the next. Dictating physicians are counting on the medical transcriptionist to be alert and, when necessary, to correct their mistakes.
2. The experienced medical transcriptionist, with a firm grasp of medical language and terminology and familiarity with the dictating physician's preferences, may edit in various ways throughout a report.
3. Where warranted, the transcriptionist may add conjunctions (and, but, for, or, nor), prepositions (of, to, in, on, with), articles (a, an, the), pronouns and nouns as the subject of a sentence, and verbs to complete a sentence. It is acceptable, however, to type as dictated, to preserve the style of the dictator.
Dictated: No tenderness present over chest.
Transcribed: No tenderness is present over the chest.
Dictated: Came in with chest pain.
Transcribed: The patient came in with chest pain.
Dictated: No tenderness on palpation
Transcribed: No tenderness was elicited on palpation.
4. As a general rule, the history portion of medical reports is dictated in the past tense. Some physicians, however, dictate in the present tense even when discussing past events. While some dictators expect the transcriptionist to change the report to past tense, others want the report to be transcribed as dictated.
5. Some dictators switch tenses within a report. The transcriptionist may elect to transcribe as dictated or edit the report to one tense for consistency, if the dictator's preference is not known. Be careful, however, as tense may change from present to past to future within a single sentence and be entirely appropriate.
The patient comes in today, stating she had a bad fall yesterday and will not be able to rest until her pain is relieved.
6. Editing also includes watching for medical inconsistencies within a report, such as a hysterectomy reportedly done on a man, or different ages given for the same patient within one report, or a surgery that begins on the left leg and ends on the right. If an inconsistency cannot be resolved, the word or phrase in question should be flagged to the dictator's attention for clarification.
1. An eponym is a place or thing which takes its name from a person (living or dead, real or imaginary). In the language of medicine, eponyms abound. Surgical instruments, medical devices, operative procedures, and anatomic structures are frequently named after the person who made the discovery or invention. An eponym that is used as an adjective is usually capitalized; the noun which follows is not.
Lyme disease Down syndrome
Tinel's sign Kirschner rod
Buck's fascia Achilles heel
2. A word derived from an eponym is generally not capitalized.
cesarean section (from Julius Caesar)
parkinsonian (from Parkinson's disease)
kocherized (from Kocher clamp)
jacksonian seizure (from Jackson)
1. When a medical transcriptionist and supervisor have un-resolved questions about dictated words or phrases in a report, the report should be "flagged" to the attention of the dictator. A self-stick note, a colored removable tab, or a paper-clipped note should be attached to the document.
2. The note attached to the report should clearly identify the words or phrases in question and, if appropriate, include a phonetic rendering of what the word or phrase "sounds like."
1. Various medical report formats and styles exist nationwide. On the job, transcriptionists use the report formats ap-proved by their transcription supervisor or department head.
2. Headings. The purpose of headings and subheadings is to categorize medical data so that important information is easy to locate within the report. Generally speaking, the transcriptionist may add headings and subheadings to a dictated report as appropriate.
The transcriptionist should also be alert for important headings that are not dictated but are a vital part of the report, such as Diagnosis or Impression in a history and physical examination report, or Final Diagnosis in a discharge summary, and Preoperative Diagnosis and Postoperative Diag-nosis in an operative report. If any of these headings are not dictated, the transcriptionist should supply them and flag the report to the attention of the dictator so that the Diagnosis can be stated.
3. Adding headings not dictated. If a physician dictates a narrative portion that belongs under a particular heading but fails to dictate the heading, the transcriptionist may insert the proper heading. For example, it is not un-common for physicians to finish dictating the physical ex-amination section of a discharge summary and begin to dictate laboratory test results or x-ray results without giving a heading for a new section. The transcriptionist should paragraph after the Physical Examination and may insert an appropriate paragraph heading such as Laboratory Data or Laboratory and X-ray Data before transcribing the information.
Exception: Some physicians do not dictate an initial heading (Chief Complaint or History, for example) but begin by detailing the events that led to the patient's hospitalization. Because the information at the beginning of a report is distinct and clearly evident, it is not necessary to add a heading here if one is not dictated, although it is accept-able to do so. The transcriptionist on the job would follow the dictator's preference, if such preference is known, or the format specified by the transcription department where the dictation originated.
PHYSICAL EXAMINATION: The fracture site was ten-der to palpation. He had good sensation and circulation in the leg. Multiple views of the tibia revealed there was a stairstep-type fracture at the distal portion of the tibia. The CBC and differential were normal.
PHYSICAL EXAMINATION: The fracture site was tender
to palpation. He had good sensation and circulation in the leg.
LABORATORY AND X-RAY DATA: Multiple views of the tibia revealed there was a stairstep-type fracture at the distal portion of the tibia. The CBC and differential were normal.
4. Abbreviations in Headings. Doctors may take shortcuts by dictating abbreviations, even for major report headings, such as CC (Chief Complaint) and HPI (History of Pres-ent Illness). Headings should always be spelled out in full. Note: Do not confuse a CC dictated for Chief Complaint with the other definitions of the abbreviation cc: cubic centimeter and carbon copy.
5. Diagnosis/Diagnoses. If a physician dictates the singular form Diagnosis and then lists several diagnoses, the transcriptionist may use either Diagnosis or Diagnoses to head the list.
6. Numbered diagnoses listed vertically. Physicians frequently number the diagnoses and want them listed vertically for ease in reading. The transcriptionist may elect to enumerate a long list of diagnoses, whether or not numbers are dictated. Occasionally a dictator will begin to number the diagnoses and then give only one diagnosis; in that case, omit the number (no need for a 1 without a 2). Be aware that in listing several diagnoses, dictators often lose track of the next number. They may inadvertently give the wrong number (which should be corrected by the transcriptionist) or delegate the numbering to the transcriptionist by saying "number next" to indicate the next diagnosis.
7. Varied acceptable formats. There are several acceptable formats for medical reports, and even alternative acceptable formats for the same sentence.
Dictated: Extremities unremarkable.
The extremities are unremarkable.
EXTREMITIES: The extremities are unremarkable.
8. Paragraphing. Transcribe paragraphs as dictated unless paragraphing would alter the medical meaning or con-tinuity of the report. Paragraphing may be added to break up long reports appropriately, to set up a new heading and its accompanying paragraph, and to separate the findings from the operative procedure. Be aware that when some physicians dictate "new line," they mean to begin a new paragraph.
9. Standard formats. With the advent of computers, many hospitals and clinics have instituted standard format outlines for each type of report dictated. These are stored in the computer's memory as templates that can be "pulled up" by the transcriptionist. This practice has introduced greater conformity in format style within an institution and has made adjusting and remembering formats relatively painless.
Headings. See Format.
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, nei-ther 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.
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.
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, be-hind, 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. Some-times 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
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
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 ad-jective or participle modifying a noun.
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.)
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
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.
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 modi- fies. 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 51 ¼2-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
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 num-ber 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 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 37.5 degrees Celsius or
Paragraphing. See Format.
1. In medical transcription, parentheses are used to set off closely related words, to clarify, or to distinguish data.
This hyperactive young lad has been on Cylert (pemoline) for several months.
2. Parentheses are often used to separate normal laboratory values from the patient's values.
Uptake by the thyroid gland at 6 hours was 5.5% (normal 4-12%); 24-hour uptake was 14.0% (normal 7-24%).
3. Parentheses should be used to set off less forceful mate-rial as compared to a dash but more forceful as compared to a comma or comma pair.
She feels (and I strongly agree) that a 1000-calorie ADA diet is not sufficient.
1. Some physicians are very consistent in dictating periods to denote the end of a sentence. Others dictate them sporadically, and still others never use them in dictation. The transcriptionist should be aware that the physician frequently loses track of what punctuation was dictated, and thus it is up to the transcriptionist to supply periods and other punctuation marks as appropriate.
2. Physicians educated in foreign countries may use the term stop or full stop to denote a period. Physicians from the Middle East often say "perr-ud" instead of period.
1. Generally, medical words derived from Latin or Greek are pluralized according to guidelines in the recommended references. Occasionally, some physicians prefer to pluralize Latin terms in the same way that English words are pluralized, and the transcriptionist follows the dicta-tor's preference unless it is incorrect. Many physicians dictate an incorrect plural for diverticulum; it is diver- ticula, not -ae or -i, as frequently dictated.
fistulas or fistulae fossas or fossae
hernias or herniae scleras or sclerae
2. See Apostrophes for further guidelines on plurals.
Pronouns: Which, Who, That
1. The pronoun which used as a relative pronoun (a noun substitute used to introduce clauses) refers to animals and things. Which is often used in nonessential clauses, which are set off by commas and are not necessary to the meaning of the sentence:
The medicine that he took, which he left at home in Virginia, was Dyazide.
2. The pronoun who (or whom) refers to people and some-times animals.
3. The pronoun that can refer to any of the above. That is used almost exclusively to introduce essential clauses (clauses that are necessary for the understanding of the sentence and not set off by commas):
The medicine that he took is unknown to me.
4. A good test of some essential clauses is to leave out the relative pronoun, and if the sentence still makes sense, it is an essential clause (example A). In example B, however, the relative clause is essential, but that cannot be omitted.
The medicine that he took is unknown to me.
The medicine he took is unknown to me.
The chamber that receives oxygenated blood from the
lungs is the left atrium.
5. Who and whom can be used in essential or nonessential clauses. Which and that can sometimes be interchanged, but which should not be used to refer to persons.
1. Proofreading involves looking for mistakes of all types in the transcribed document and correcting them. The usual types of errors that occur include omitting important dic-tated words, selecting the wrong English or medical word, misspelling words, and making typographical, grammati-cal, or punctuation errors.
2. Medical transcriptionists should conscientiously look up all unfamiliar words and spellings. They should proofread on the screen as they are transcribing and always carry out a final proofing on the screen (or in hard copy if they have access to the printout), especially if there is not a pro-fessional proofreader reviewing the transcribed work.
1. Medical transcriptionists should never, on their own ac-cord, insert a question mark within a document to denote a word they consider to be unclear or unknown. The ap-propriate 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 (?).
1. Quotation marks are used to denote the exact words of a patient as specified by the dictator.
Dictated: The patient states quote I feel lousy unquote. Transcribed: The patient states, "I feel lousy."
2. Physicians occasionally dictate quotation marks to set off unusual or slang terms. Quotation marks are also used to denote a word for special attention.
The patient told me that she had "firebirds" in her uterus, but I believe she meant "fibroids."
1. Use a semicolon to separate two independent clauses that are not joined by a conjunction such as and, but, for, or, nor, but are related in meaning. In the following example,
the semicolon takes the place of a period.
Lungs are clear to auscultation; no rales or rhonchi are
2. If the word however or therefore separates two independent clauses, place a semicolon before the word and a comma after it.
The patient was very tired; however, he did not complain of weakness.
Dr. Campbell reported that the pathology specimen was negative; therefore, no further follow-up is necessary.
3. Use a semicolon to separate main sections when the separate internal elements are already separated by commas.
Heart: Regular rate and rhythm; no murmur, gallop,
or rub; Sl and S2 normal.
Slang. See Brief Forms and Medical Slang.
Slash Mark. See Symbols.
1. Some words have more than one acceptable spelling. The preferred spelling of a word always appears in a dictionary as the main entry followed by the definition and subentries. Alternative spellings are not usually followed by a defini-tion but by the preferred spelling, directing the reader back to the preferred spelling and definition.
2. In some instances, a physician attempts to spell a medical term for the transcriptionist. These spellings are often erroneous, and the transcriptionist should realize that the at-tempted spelling is only a starting point from which to word-search in a reference book.
3. Preferred spellings may vary among English and medical references.
Preferred Spelling Acceptable Spelling
4. Physicians frequently dictate combined forms of anatomi-cal words and directions. When the physician's preference is not clear, it is acceptable to use either the combined form or the hyphenated form. Note that when the two hyphenated words are merged into a combined form, the spelling of the first word often changes.
Hyphenated Form Combined Form
5. Some medical words are spelled differently when their form changes.
Achilles tendon tendo Achillis
fascia late tensor fasciae latae
Subject-Verb Agreement. See Agreement.
Subscripts and Superscripts
1. Subscripts and superscripts are seldom used by tran-scriptionists in medical reports because they are not easily executed, even on computer keyboards. Also,
on typewritten reports it may be difficult for the reader
to determine whether a number is a subscript for one line or a character on the line below it.
2. When a term that would ordinarily have a subscript is written with all characters on the baseline, no spaces or hyphens are used.
A2, P2 A2, P2
V1, V6 V1, V6
3. The most common terms that would have subscripts in medical reports include the following:
blood gases PCO2, PO2
chemical symbols O2, CO2
heart sounds S1, S2, S3, S4
thyroid tests T3, T4
4. The most common terms with superscripts in medical reports are elements such as those used in radiology and radiotherapy. When a term that would ordinarily have a superscript is written with all characters on the baseline, the superscript number that ordinarily precedes the ele-ment symbol now follows the symbol, and a space (not a hyphen) is used to separate the letters from the numerals.
technetium 99mTc sulfur colloid
technetium Tc 99m sulfur colloid
iodohippurate sodium 131I
iodohippurate sodium I 131
sodium iodide 125I
sodium iodide I 125
gallium citrate 67Ga
gallium citrate Ga 67
5. A superscript is used occasionally in laboratory data, e.g., when values are given to a certain power. These numbers should be transcribed as dictated.
Dictated: The WBC count was ten to the fifth power. Transcribed: The WBC count was 105.
Dictated: Red blood cells were five times ten to the
Transcribed: Red blood cells were 5 x 106.
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.
Tense. See Format.
Units of Measure. See Numbers.
Verb-Subject Agreement. See Agreement.