Style Guide

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Basic Style Guide Courtesy of Global Medical Transcription and MT Daily The 2005 changes made by AAMT are not included in this style guide. These are the generally accepted rules of medical transcription as taught by GMT. Client preference will always take precedence. We encourage your input for additions to this page. Include them in an email to The GMT Webmaster. We created this list for our students as a quick reference of generally accepted rules of medical transcription.  It is not intended to supplant any other publication regarding transcription style.  We publish it here solely as a service to the MT community.  We hope you find it useful.- GMT Caveat:   In medical transcription, the Golden Rule applies. "Those with the gold make the rules."  Therefore, client preference always takes precedence. Basic Rules of Transcription I. Spacing With Punctuation Marks Do Not Type a Space ... following a period with an abbreviation  following a period used as a decimal point  between quotation marks and the quoted material  before or after a hyphen  before or after a slash  before or after a dash  between a number and percent sign  between parentheses and the enclosed material  between any word and the punctuation following it.  between the number and the colon used to indicate a dilute solution or ratio.  on either side of the colon when expressing the time of day  before an apostrophe  before or after a comma used within numbers  before or after an ampersand in abbreviations, e.g., C&S  on either side of the colon when expressing ratios e.g. 1:1  after the closing parenthesis if another mark of punctuation follows  Type One Space...  between words  after a comma  after a semicolon  after a period following an initial  after the closing parenthesis  on each side of the x in an expression of dimension, e.g. 4 x 4  Type Two Spaces... after punctuation at the end of a sentence  after a colon except when expressing time or a dilution ratio  II. Numbers Spell out WHOLE numbers zero through nine, use numerals for 10 and above (this may change in the near future as the AAMT is trying to standardize using numerals only. When the next edition of the AAMT Book of Style is published (Spring 2002), you can probably expect new guidelines).  Use numerals when numbers are directly used with symbols.  Use numerals when expressing ages.  If it is an approximate age, spell it out.  Use numerals to express size and measurements.  Use numerals for everything metric. Centimeters, millimeters, liters, etc.  Use numerals in all expressions pertaining to drugs - this includes strength, dosage and directions. Z-PAK 2 daily on day 1, then 1 daily on days 2-5.  Spell out and hyphenate fractions standing alone. He drank one-half a gallon of apple juice.  Use numerals to express mixed fractions. 1 1/2 years.  Use commas only if there are 5 or more digits when expressing numbers.  e.g. 10,000, 4000. Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration.  Substitute a hyphen for the word "to". He is to take 1-2 tablets of Tylenol every 4-6 hours p.r.n.  Leave a space between numerals and measurements unless they form a compound modifier. It is 6 cm below the ...... It is 1200 ml....... A 4-cm nevus....... A 2 x 2-mm lesion.......  Always use 0 in front of the decimal point if the number is not a whole number.  0.75 mg Use decimal fractions with metric measurements. 1.5 cm  Use mixed fractions with English system measurements. 1 1/2 inch Use numerals for: Ages, units of measure, vital statistics, lab values and in other instances where it is important to communicate clearly the number referenced.  Examples:  4 inches, 3-year-old.  She has three dogs who have eight fleas each.  A total of 7 basal cell carcinomas removed from his left arm.  (7 for clarity)  Do not start a sentence using a number. Spell out the number or recast the sentence.  Dictated as: 10 milligrams of Reglan was administered stat.  Transcribe as: Reglan 10 mg was administered stat.  Exception - It is acceptable to begin a sentence with a date.  Example - 2000 is going to be a prosperous year.  Plurals - do not use an apostrophe to form plural numbers.  4 x 4s  She was in her 20s or twenties (this is acceptable because it is not a definite number).  She was born in the 1970s.  Series of numbers - Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction.  Example - Jeff has 1 job, 1 place of employment and 18 hours a day to do the work.  Cranial nerves - Preferred: Roman numerals I-XII  Diabetes type 1 and type 2, not Roman numerals I and II - this was recently standardized by the American Diabetes Association. Apgar scores - Use numerals for ratings and spell out numbers relating to minutes. Rationale - to draw attention to the scores.   Example: The Apgar scores were 6 and 9 at one and five minutes.  Apgar is not an acronym. Time Examples  8:30 a.m. - morning  8:30 p.m. - evening  noon, not 12:00 noon  midnight, not 12:00 midnight or 12 'o'clock or 12:00 p.m.  III. Measurements Spell out all nonmetric measurements. Feet, inches, pounds, ounces, yards, grain, dram, etc.  Exceptions: Use tsp for teaspoon  Use tbsp for tablespoon  Abbreviate all metric measurements. Use F for Fahrenheit IF accompanied by the symbol for degree. 98.6�F  Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit.  Use C for Celsius IF accompanied by the symbol for degree. 36�C  Spell out Celsius IF degree is spelled out. 36 degrees Celsius.  In tables and technical documents:  Use ft or ' for feet Use " for inches Use yd for yard  Use pt for pint  Use oz for ounce  Use fl oz for fluid ounce  Abbreviate most unusual units of measure when accompanied by numerals Dictated as Transcribed as 0.8 centimeters squared 0.8 sq cm 22 milligram of mercury  22 mmHg 3.0 liters per minute 3.0 L/min 40 millimeters per hour  40 mm/h 8 grams percent  8 gm% IV. Symbols  Spell out a symbol when used alone (with no number).  Use symbols when they are used with numbers  Common Symbols    Dictated as Transcribed as Four to five 4-5  Number 3 0  #3-0  Twenty-twenty vision 20/20  BP 120 over 80 120/80  Grade two over six 2/6  A positive A+  Three point five centimeters  3.5 cm  Point five centimeters 0.5 cm V. Capitalization Capitalize... Abbreviations when the words they represent are capitalized  The first word following a colon if it begins a complete sentence or is part of an outline entry  Most abbreviations of English words  The first letter of chemical elements  The names of the days of the week, months, holidays, historic events and religious festivals  The names of specific departments or sections in the institution only when the institution name is included  The names of diseases that include proper nouns, eponyms or genus names  The trade or brand names of drugs  A quote when it is a complete sentence  The names of races, peoples, religions and languages. Black, as a race designation would be capitalized, however client preferences may differ. Do Not Capitalize... The spelled out names of the chemical elements  The seasons of the year  The common names of diseases  The names of viruses unless they include a proper noun  Generic drug names  The common noun following the brand name. Example - Tylenol tablets  The names of medical or surgical specialties  Designations based on skin color, like "a tall white man."  VI. Hyphenation These prefixes do not require the use of a connecting hyphen in compound terms:    ante intra semi anti micro sub bi mid super co non supra contra over trans counter pre tri de post  ultra extra pro un infra pseudo under inter re  weight Examples - antecubital not ante-cubitalAlso Correct - antithesis, bitemporal, counterproductive, defibrillated, extrapyramidal, infraumbilical, interpersonal, intracranial, microhematuria, midline, nontender, nondistended, nonfocal, nonspecific, noncontributory, noncompliance, nonicteric, nonsmall, overestimate, overweight, preoperative, postoperative, posttraumatic, pseudogout, semicircular, sublingual, superimposed, supramammary, transvaginal, ultraviolet, underweight, weightbearing. Do use a hyphen with prefixes ending in a or i and a base word beginning with the same letter. Example - anti-inflammatory. Do use a hyphen when compounded with the prefix self.  Example - self-administered, self-monitored.  For Clarification - Use a hyphen after a prefix if not using a hyphen would change the meaning of the word.  Examples - re-cover (to cover again) versus recover (regain)   VII. Cancer Classifications  Stage and grade - do not capitalize either one if it does not begin a sentence.  Use Roman numerals for cancer stages.  Use Arabic numerals for cancer grades.  For clarity, use capital letters or arabic suffixes without spaces or hyphens. Here are some examples:  stage 0  stage I stage IA  stage II  stage III  stage IIIA stage IIIB stage IV  grade 1  grade 2  grade 3  grade 4  VIII. Drug Terminology If dictated q.day - transcribe q.d.  If dictated q. four hours - transcribed as q.4h. not q. 4 hours.  When referring to drugs including strength, dosage and directions - Use Arabic numerals only.  Example - The patient was prescribed penicillin 500 mg t.i.d. for 5 days.  If there is no whole number, always add a 0 in front of the decimal point for clarity - this is a general rule when transcribing numbers, not just medications.  Example - Dictated as Synthroid point 75 mg a day.  Transcribe as Synthroid 0.75 mg q.d.  Be aware that some drugs are commonly dictated in either milligrams or micrograms. Example -  Synthroid 0.05 mg or Synthroid 50 mcg.  IX. Lab Test Punctuation Guidelines Use commas to separate multiple related test results. Here are some examples:  Creatinine 1.2, BUN 42, phosphorus 4.3.  WBC 12.4 with 72 segs, 9 lymphs.  CBC reveals an RBC count of 10.2, WBC 6.8, platelets 220,000, reticulocyte count 1 with 3 monos, 1 eos and 0 basos.  Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100 and glucose of 80.  Use periods to separate unrelated laboratory test results. For example,  Potassium 3.7. TSH 1.0. Albumin 4.0.  X. Miscellaneous  Keep logically connected items on the same line. Drug doses, names, dates, sets, etc.  Examples: Lopressor 100 mg. Keep all 3 items on the same line.  Dr. Fred Farnsworth. Keep the doctors title and full name on the same line.  January 14, 2000. Keep the entire date on the same line.  100 pounds. Keep both words on the same line.  5 inches. Same rule.  Names Names with junior or senior attached. Use a comma before and a period after the abbreviation or use neither.  Example - Jeramiah Johnson, Jr. or Jeramiah Johnson Jr  Incorrect - Jeramiah Johnson Jr.  Names with ordinals. Do not use comma between name and ordinal.  Example - Bernie Schwartz III  Incorrect - Bernie Schwartz, III  XI. Report Section Notes History of Present Illness - Mainly in present tense, but mixed tense may be appropriate.  Past Medical History - Use past tense. Allergies Allergies are typed either ALL CAPITAL LETTERS or bold font depending on client preference.  Example - If the allergy is dictated pcn, type PENICILLIN.  If the patient has no allergies use the phrase, "No known drug allergies."  Medications Transcribe in continuous paragraph format, even when the doctor numbers the medications.  Example: Penicillin 500 mg t.i.d. for 5 days, levothyroxine 0.75 mg q.d. and Lopressor 50 mg b.i.d.  Capitalize brand name medications. DO NOT capitalize generic medications.  Use Latin drug abbreviations.  Example - if dictated every day - transcribe q.d.  If dictated every four hours - transcribe q.4h. not q. 4 h.  Don't mix Latin and English terminology.  Example:  If dictated q. day - transcribe q.d. NOT q. day.  When referring to strength, dosage and directions - Use Arabic numerals only.  If there is no whole number, add a zero in front of the decimal point for clarity. This is a general rule when transcribing numbers, not just medications.  Example:  Dictated as Synthroid point 75 milligrams a day. Transcribe Synthroid 0.75 mg q.d. Physical Examination Transcribe in present tense in ALL of the major report formats.  Vital Signs - Should look like this:  Temperature 98.0, BP 140/80, pulse 76 and regular, respirations 16.  Assessment/Diagnosis/Impression Typed entirely in upper case.  No abbreviated medical terminology.  Type the entire term or phrase.  Example - If the doctor dictates CAD, type coronary artery disease. Numbers follow the same rules for any section of the transcript.  Example - A 31-YEAR-OLD FEMALE.  5 MG.  Abbreviate units of measure, e.g. MG, MM, CM, etc.  The title Doctor is written out, not abbreviated. Verb tenses Use past tense:  In the past history of a report  In discharge summaries EXCEPT for the History of Present Illness and the Physical Examination sections.  When discussing expired patients  Use present tense: To describe the physical examination  Use the correct verb tense to communicate the appropriate time of the action. Even if the dictator inadvertently changes tense during the dictation.  XII. Things to check when proofreading a document Fill in blanks or make notes Consistent pronouns - he or she?  Consistent tense - was or is?  Consistent left and right alignment Singulars versus plurals - sclera or sclerae? Headings - Are they labeled properly?  Sound-Alikes Unnecessary awkward repetitions No abbreviations in diagnoses or procedures Drugs correctly capitalized Formatting, headings and indentations Proper use of hyphens Dates Complete sentences Punctuation We encourage your input for additions to this page. Include them in an email to The GMT Webmaster. Copyright � 1999, 2000, 2001, 2002  Global Medical Transcription, Inc.