Integumentary System
The skin and its accessory organs (hair, nails, and glands) are the integumentary system of the body. Integument means covering.
Skin contains two types of glands that produce important secretions. These glands under the skin are the sebaceous and the sweat glands.
Sebaceous glands produce sebum, an oily secretion, and sweat glands produce sweat, a watery secretion.
Layers of the skin
Squamous epithelial cells are flat and scale-like. In the outer layer of the skin, these cells are arranged in several layers (strata) and are therefore called stratified squamous epithelium.
apocrine sweat gland: One of large dermal exocrine glands located in the axilla and genital areas.
Basal layer: The deepest region of the epidermis; it gives rise to all the epidermal cells.
collagen: Structual protein found in the skin and connective tissue.
Stratum corneum: The outermost layer of the epidermis, which consists of flattened, keratinized (horny) cells.
keratin: Hair protein material found in the epidermis, hair, and nails. Keratin means horn and is commonly found in the horns of the animals. The basal layer of the epidermis contains special cells called melanocytes. Melanocytes form and contain a brown-black pigment called melanin.
albino: Person with skin deficient in pigment (melanin)
lunula: is a semilunar (half-moon), white region at the base of the nail plate.
paronychium: is the soft tissue surrounding the nail border.
cuticle: a narrow, band of epidermis (layer of keratin)
epithelium: Layer of skin cells forming the outer and inner surfaces of the body.
hair follicle: Sac within which each har grows.
lipocyte: A fat cell.
melanin: Major pigment that gives the skin color. It is formed by melanocytes in the epidermis.
pors: Tiny opening on the surface of the skin.
sebum: Oily substance secreted by sebaceous glands.
squamous epithelium: Flat, scale-like composing the epidermis.
statified: Arranged in layers.
stratum (plural: strata) : A layer (of cells).
stratum corneum: The outermost layer of the epidermis, which consists of flattened, keratinized (horny) cells.
epidermis: Outer most layer of the skin.
dermis: Middle layer of the skin; also called corium.
subcutaneous tissue: The innermost layer of the skin, containing fat tissue.
Integumentary System - Combining Forms and Suffixes
adip/o - fat
lip /o - fat
steat/o - fat
albin/o - white
leuk/o - white
anthrac/o - black (as coal)
chlor/o - green
cirrh/o - tawny yellow
jaund/o - yellow
xanth/o - yellow
lute/o - yellow
cyan/o - blue
eosin/o - rosy
erythr/o - red
melan/o - black
poli/o - gray
caus/o - burn, burning
cauter/o - heat, burn
cutane/o - skin
derm/o - skin
dermat/o - skin
diaphor/o - profuse sweating
erythem/o - redness
erythemat/o - redness
hidr/o - sweat
ichthy/o - (fish-like) - scaly, dry
kerat/o - hard, horny tissue
lip/o - fat
myc/o - fungus (fungi include yeasts, molds, and mushrooms)
onych/o - nail
ungu/o - nail
phyt/o - plant
pil/o - hair
trich/o - hair
rhytid/o - wrinkle
seb/o - sebum (oily secretion from sebaceous glands)
squam/o - scale-like
steat/o - fat
trich/o - hair
ungu/o - nail
xanth/o - yellow
xer/o - dry
Suffixes
-derma -> skin
Integumentary System - Lesions, Signs and Symptoms, Abnormal Conditions, and Skin Neoplasms
Integumentary System - Cutaneous Lesions
crust: Collection of dried serum and cellular debris.
cyst : Thick-walled, closed sac or pouch containing fluid or semisolid material.
erosion: Wearing away of loss of epidermis.
fissure: Groove or crack-like sore.
polyp: Mushroom-like growth extending on a stalk from the surface of mucous membrane.
ulcer: Open sore on the skin or mucous membrane.
vesicle: Small collection of clear fluid (serum); blister.
wheal: Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin.
macule: Discolored (often reddened) flat lesion.
nodule: Solid, elevated lesion more than 1 cm in diameter. (>1 cm - nodule)
papule: Solid, elevated lesion less than 1 cm in diameter. (<1 cm - papule)
pustule: Small elevation of the skin containing pus.
Integumentary System - Signs and Symptoms
alopecia: Absence of hair from areas where it normally grows.
ecchymosis (plural - ecchymoses): Bluish-black mark (macule) on the skin; black-and-blue mark. (ec- means out and chym/o means pour)
petechia (plural - petechiae): A small, pinpoint hemorrage.
pruritus: Itching.
purpura: Merging ecchymoses and petechiae over any part of the body.
urticaria(hives): Acute allergic reaction in which red, round wheals develop on the skin.
Integumentary System - Abnormal Conditions
acne: Papular and pustular eruption of the skin.
burns: Injury to tissues caused by heat.
cellulitis: Diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling.
eczema: Inflammatory skin disease with erythematous, papulovesicular lesions.
exanthematous viral diseases: Rash (exanthem) of the skin due to a viral infection.
gangrene: Death of tissue associated with loss of blood supply.
impetigo: Bacterial inflammatory skin disease characterized by vesicles, pustules, and crusted-over lesions.
psoriasis: Chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales.
scabies: A contagious, parasitic infection of the skin with intense pruritus.
scleroderma: A chronic progressive disease of the skin with hardening and shrinking of connective tissue.
systemic lupus erythematosus(SLE): Chronic inflammatory disease of collagen in the skin, of joints, and of internal organs.
tines: Infection of the skin caused by a fungus.
vitiligo: Loss of pigment (depigmentation) in areas of the skin (milk-white patches). Also known as leukoderma.
Integumentary System - Skin Neoplasms
callus: Increased growth of cells in the keratin layer of the epidermis caused by pressure or friction.
keloid: Hypertrophied, thickened scar that occurs after trauma or surgical incision.
keratosis: Thickened area of the epidermis.
leukoplakia: White, thickened patches on mucous membrane tissue of the tongue or cheek.
nevus (plural - nevi): Pigmented lesion of the skin.
verruca: Epidermal growth caused by a virus(wart).
Integumentary System - Cancerous Lesions
basal cell carcinoma: Malignant tumor of the basal cell layer of the epidermis.
Kaposi sarcoma: Malignant, vascular, neoplastic growth characterized by cutaneous nodules. Frequently on the lower extremities.
malignant melanoma: Cancerous growth composed of melanocytes.
squamous cell carcinoma: Malignant tumor of the squamous epithelial cells of the epidermis.
Integumentary System - Clinical Procedures
cryosurgery: Use of subfreezing temperature via liquid nitrogen application to destroy tissue.
curettage: Use of sharp dermal curet (curette) to scrape away a skin lesion.
electrodesiccation: Tissue is destroyed by burning with an electric spark.
Mohs surgery: Thin layers of malignant growth are removed, and each is examined under a microscope.
skin biopsy: Suspected malignant skin lesions are removed and sent to the pathology laboratory for microscopic examination.
skin test: The reaction of the body to a substance by observing the results of injecting the substance intradermally or applying it topically to the skin.
Integumentary System - Abbreviations
ABCD - asymmetry, border, color, diameter; characteristics associated with skin cancer.
bx - biopsy.
Derm. - dermatology.
DLE - discoid lupus erythematosus.
PPD - purified protein derivative; skin test for tuberculosis.
PUVA - psoralen-ultraviolet (A light therapy).
SLE - systemic lupus erythematosus
subcut - subcutaneous.
Skin contains two types of glands that produce important secretions. These glands under the skin are the sebaceous and the sweat glands.
Sebaceous glands produce sebum, an oily secretion, and sweat glands produce sweat, a watery secretion.
Layers of the skin
Integumentary System - Vocabulary
- Epidermis : a thin, cellular membrane layer (Outermost layer of the skin).
- Dermis (Corium) : Middle layer of the skin. Dense, fibrous, connective tissue layer. (Sebaceous glands are located in dermal layer. They secrete an oily substance called sebum)
- Subcutaneous tissue: thick, fat-containing tissue. (Lipocytes are predominant in the subcutaneous layer)
Squamous epithelial cells are flat and scale-like. In the outer layer of the skin, these cells are arranged in several layers (strata) and are therefore called stratified squamous epithelium.
apocrine sweat gland: One of large dermal exocrine glands located in the axilla and genital areas.
Basal layer: The deepest region of the epidermis; it gives rise to all the epidermal cells.
collagen: Structual protein found in the skin and connective tissue.
Stratum corneum: The outermost layer of the epidermis, which consists of flattened, keratinized (horny) cells.
keratin: Hair protein material found in the epidermis, hair, and nails. Keratin means horn and is commonly found in the horns of the animals. The basal layer of the epidermis contains special cells called melanocytes. Melanocytes form and contain a brown-black pigment called melanin.
albino: Person with skin deficient in pigment (melanin)
lunula: is a semilunar (half-moon), white region at the base of the nail plate.
paronychium: is the soft tissue surrounding the nail border.
cuticle: a narrow, band of epidermis (layer of keratin)
epithelium: Layer of skin cells forming the outer and inner surfaces of the body.
hair follicle: Sac within which each har grows.
lipocyte: A fat cell.
melanin: Major pigment that gives the skin color. It is formed by melanocytes in the epidermis.
pors: Tiny opening on the surface of the skin.
sebum: Oily substance secreted by sebaceous glands.
squamous epithelium: Flat, scale-like composing the epidermis.
statified: Arranged in layers.
stratum (plural: strata) : A layer (of cells).
stratum corneum: The outermost layer of the epidermis, which consists of flattened, keratinized (horny) cells.
epidermis: Outer most layer of the skin.
dermis: Middle layer of the skin; also called corium.
subcutaneous tissue: The innermost layer of the skin, containing fat tissue.
Integumentary System - Combining Forms and Suffixes
adip/o - fat
lip /o - fat
steat/o - fat
albin/o - white
leuk/o - white
anthrac/o - black (as coal)
chlor/o - green
cirrh/o - tawny yellow
jaund/o - yellow
xanth/o - yellow
lute/o - yellow
cyan/o - blue
eosin/o - rosy
erythr/o - red
melan/o - black
poli/o - gray
caus/o - burn, burning
cauter/o - heat, burn
cutane/o - skin
derm/o - skin
dermat/o - skin
diaphor/o - profuse sweating
erythem/o - redness
erythemat/o - redness
hidr/o - sweat
ichthy/o - (fish-like) - scaly, dry
kerat/o - hard, horny tissue
lip/o - fat
myc/o - fungus (fungi include yeasts, molds, and mushrooms)
onych/o - nail
ungu/o - nail
phyt/o - plant
pil/o - hair
trich/o - hair
rhytid/o - wrinkle
seb/o - sebum (oily secretion from sebaceous glands)
squam/o - scale-like
steat/o - fat
trich/o - hair
ungu/o - nail
xanth/o - yellow
xer/o - dry
Suffixes
-derma -> skin
Integumentary System - Lesions, Signs and Symptoms, Abnormal Conditions, and Skin Neoplasms
Integumentary System - Cutaneous Lesions
crust: Collection of dried serum and cellular debris.
cyst : Thick-walled, closed sac or pouch containing fluid or semisolid material.
erosion: Wearing away of loss of epidermis.
fissure: Groove or crack-like sore.
polyp: Mushroom-like growth extending on a stalk from the surface of mucous membrane.
ulcer: Open sore on the skin or mucous membrane.
vesicle: Small collection of clear fluid (serum); blister.
wheal: Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin.
macule: Discolored (often reddened) flat lesion.
nodule: Solid, elevated lesion more than 1 cm in diameter. (>1 cm - nodule)
papule: Solid, elevated lesion less than 1 cm in diameter. (<1 cm - papule)
pustule: Small elevation of the skin containing pus.
Integumentary System - Signs and Symptoms
alopecia: Absence of hair from areas where it normally grows.
ecchymosis (plural - ecchymoses): Bluish-black mark (macule) on the skin; black-and-blue mark. (ec- means out and chym/o means pour)
petechia (plural - petechiae): A small, pinpoint hemorrage.
pruritus: Itching.
purpura: Merging ecchymoses and petechiae over any part of the body.
urticaria(hives): Acute allergic reaction in which red, round wheals develop on the skin.
Integumentary System - Abnormal Conditions
acne: Papular and pustular eruption of the skin.
burns: Injury to tissues caused by heat.
- first-degree burns: superficial epidermal lesions, erythema, hyperesthesia, and no blisters. (Ex: Sunburn).
- second-degree burns: partial-thickness burn injury.
- third-degree burns: full-thickness burn injury.
cellulitis: Diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling.
eczema: Inflammatory skin disease with erythematous, papulovesicular lesions.
exanthematous viral diseases: Rash (exanthem) of the skin due to a viral infection.
gangrene: Death of tissue associated with loss of blood supply.
impetigo: Bacterial inflammatory skin disease characterized by vesicles, pustules, and crusted-over lesions.
psoriasis: Chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales.
scabies: A contagious, parasitic infection of the skin with intense pruritus.
scleroderma: A chronic progressive disease of the skin with hardening and shrinking of connective tissue.
systemic lupus erythematosus(SLE): Chronic inflammatory disease of collagen in the skin, of joints, and of internal organs.
tines: Infection of the skin caused by a fungus.
vitiligo: Loss of pigment (depigmentation) in areas of the skin (milk-white patches). Also known as leukoderma.
Integumentary System - Skin Neoplasms
callus: Increased growth of cells in the keratin layer of the epidermis caused by pressure or friction.
keloid: Hypertrophied, thickened scar that occurs after trauma or surgical incision.
keratosis: Thickened area of the epidermis.
leukoplakia: White, thickened patches on mucous membrane tissue of the tongue or cheek.
nevus (plural - nevi): Pigmented lesion of the skin.
verruca: Epidermal growth caused by a virus(wart).
Integumentary System - Cancerous Lesions
basal cell carcinoma: Malignant tumor of the basal cell layer of the epidermis.
Kaposi sarcoma: Malignant, vascular, neoplastic growth characterized by cutaneous nodules. Frequently on the lower extremities.
malignant melanoma: Cancerous growth composed of melanocytes.
squamous cell carcinoma: Malignant tumor of the squamous epithelial cells of the epidermis.
Integumentary System - Clinical Procedures
cryosurgery: Use of subfreezing temperature via liquid nitrogen application to destroy tissue.
curettage: Use of sharp dermal curet (curette) to scrape away a skin lesion.
electrodesiccation: Tissue is destroyed by burning with an electric spark.
Mohs surgery: Thin layers of malignant growth are removed, and each is examined under a microscope.
skin biopsy: Suspected malignant skin lesions are removed and sent to the pathology laboratory for microscopic examination.
skin test: The reaction of the body to a substance by observing the results of injecting the substance intradermally or applying it topically to the skin.
Integumentary System - Abbreviations
ABCD - asymmetry, border, color, diameter; characteristics associated with skin cancer.
bx - biopsy.
Derm. - dermatology.
DLE - discoid lupus erythematosus.
PPD - purified protein derivative; skin test for tuberculosis.
PUVA - psoralen-ultraviolet (A light therapy).
SLE - systemic lupus erythematosus
subcut - subcutaneous.
Medical Transcription Questions
Transcription Referencing Quiz
TRUE or FALSE and MULTIPLE CHOICE
TRUE or FALSE and MULTIPLE CHOICE
True or False?
- Dermatitis is a painful condition of the eyes. T/F
- An eschar is a thick, coagulated crust. T/F
- Quiescent means to become very active. T/F
- Intramuscular means within the vein. T/F
- Tonsillitis is an inflammation of the tonsils. T/F
- Erythema means blueness of the skin. T/F
- Tinea pedis is a fungal infection of the hands. T/F
- Hyperpigmentation means decreased pigment in a tissue or body part. T/F
- Paroxysm means occurring at night. T/F
- Etiology means a visionary theory. T/F
- A laceration is a surgical incision made by a physician. T/F
- Cyanosis is a dark reddish coloration of the skin and mucous membranes. T/F
- The term carotid refers to a vein. T/F
- The definition of cholelithiasis is inflammation of the gallbladder. T/F
- The term normoactive would mean abnormally active. T/F
- The term hematuria means blood in the urine. T/F
- The peritoneum is the space between the anus and the scrotum or vaginal opening. T/F
- The term syncope means to faint or swoon. T/F
- The term atraumatic means to have suffered abnormally severe trauma. T/F
- The term esophagitis means inflammation of the esophagus. T/F
- A fibroadenoma is a benign neoplasm. T/F
- The term febrile means without a fever. T/F
- The term urosepsis means infection from obstruction of contaminated urine. T/F
- The term intercostal means between the ribs. T/F
- The term "in extremis" means to be extremely weak. T/F
Multiple Choice
1. Leukocytes are what types of cells?
A. Red blood cells B. Malignant cells C. White blood cells D. Plasma cells
2. The term labile, as in labile hypertension, means
A. unstable B. tagged C. explosive D. hard
3. The definition of hematemesis is
A. blood in the stool B. a blood cell C. vomiting of blood D. blood in the urine
4. The term excision means
A. cut into B. cut out C. cut off D. cut open
5. The abbreviation p.c. means
A. after a meal B. by mouth (orally) C. as required D. poison control
6. A physician may say, "I was unable to ______ a response to the Babinski reflex."
A. elicit B. illicit C. ellicit D. solicit
7. The term supine means
A. face downward B. face upward C. head flexed backward D. lying on the side
8. The term diaphoretic means
A. perspiration B. percutaneous C. diaphragm D. translucent
9. The term hepatocellular refers to cells within the
A. kidney B. gallbladder C. liver D. pancreas
10. The term suppuration is best defined as
A. above a crest B. above the maxilla C. formation of pus D. above the urinary tract
11. The term thrombosis is best defined as
A. serotonin B. clotting within a blood vessel C. megakaryocyte D. blockage
12. The term decubitus means
A. extending downward B. position of patient in bed, or dorsal C. decortication D. clubbing
13. The term atrophy means
A. abnormal sound B. wasting of tissues or organs C. inability to ambulate D. without levels
14. Ecchymosis is a term that means
A. blue patch B. purplish patch C. red patch D. black patch
15. Which one of the following measurements would not be included in arterial blood gases?
A. pH B. creatinine C. pCO2 D. pO2
Referencing Refinements
Because medical terminology uses so many Greek and Latin terms, the spellings are not always what you would expect in English.
Sound everything out and look up the sounds you are hearing based on many different ways of spelling the sounds, as in "f" or "ph," and as in "k" or "ch."
Remember, too, to work your way through the vowels after the main sound: if "ch" is the main sound you would then look up words with a-e-i-o-u-and y following "ch."
Examples:
> You hear --"a-k"--as in acanthosis; check ac, acc, ach, ak, aq
> You hear--"ace"--as in acebutolol; check ace, aci, ase, asy
> You hear--"acu"--as in acute; check in acu, accu
> You hear--"ad-e"--as in adenovirus; check ade, adi, ady
> You hear--"aero"--as in aerobic; check aro, arro, ary, ero, ery
> You hear--"alla"--as in allachesthesia; check alla, alle, allo, ala, ale, ali, allyl, alo
> You hear--"ambi"--as in ambient; check ambi, ambly, ambe
> You hear--"am-e"--as in ametropia; check ame, ami, amy
> You hear--"ank"--as in ankyloglossia; check anch, ank
> You hear--"ante"--as in antegrade; check ante, anti
> You hear--"a-f"--as in aphasia; check aph, af
> You hear--"apo"--as in apoplexy; check api, apo, ape, appe, appi, appo, apy
> You hear--"antree"--as in antresia; check antre, antri
Word Research Techniques
Word Research Techniques
The ability to research medical terms that you are not familiar with is the paramount skill that will be called on each day you practice medical transcription.
There will constantly be new terms that need to be researched in reference books, along with a need to look up potential words when the word has been dictated in a manner that makes it unclear, i.e. the physician cuts off either the first part or last part of a word.
1. Always look under the noun first.
In the following examples, the word to look up is in bold.
postsphenoidal bone / Unna's boot / tardive dystonia
submantle layer / appendiceal mass / suppurative mastitis
olivary nucleus / Hodgkin's sarcoma / growth quotient
2. If the term to be researched is a syndrome, also check under these terms: sign / disease / symptom / process / phenomenon
3. Don't forget to look up anatomical terms under their Latin names. Many physicians will give the Latin names for muscles, veins, arteries, etc. See below for a listing of several Latin names and their English equivalents.
| LATIN | ENGLISH |
| vena | vein |
| musculus | muscle |
| arteria | artery |
| ligamentum | ligament |
| nervus | nerve |
4. If you can't find the term you need under the noun, then look under each word you hear. You will eventually run into the term you are looking for. In time, this will be accomplished faster and easier with the use of Google or Yahoo opposed to the use of books.
5. A trick I have always used in researching a word is to work my way through the vowels (a, e, i, o, u, and y) in order to eventually locate the correct spelling of the word I need. In medicine, there are many words that might sound like they begin with an "a," but that really begin with another vowel. Use this trick of working your way through the vowels to eventually find the correct spelling of the word you are researching.
6. Always sound out what you are hearing and research according to every phonetic way possible of spelling the word.
For example:
If you hear "fima"... don't forget that "phy" has the same sound, so the word is "phyma."
If you hear "condro"... don't forget that this could also be "chondro" or "kondro."
If you hear "terigoid"... don't forget that in medicine, there are several terms that have the "t" sound that start with "pt." The word is "pterygoid
MT Grammar Guidelines in Brief
Mentioned below are some of the key points to remember while transcribing any document. Though some of these features may change in course of time with the oncoming AAMT style of book.
The most difficult task or rather the biggest confusion occurs while writing numbers. Here is a list of some Dos and Don’ts.
“Playing with Numbers”
• Always spell out whole numbers zero through nine and use numerals for 10 and above. Eg. This nine-year-old boy comes for a followup visit.
• Use numerals to express size and measurements.
• Use numerals for every sort of measurement. Centimeters, millimeters, liters, etc.
• Use numerals in all expressions pertaining to drugs - this includes strength, dosage and directions. Eg. Tamoxifen 20 mg daily, or Xeloda 1000 mg on days 2-5.
• Spell out fractions and hyphenate them when standing alone. Eg: She drank one-half liter of Ensure.
• Use numerals to express mixed fractions. 1½ months.
• Use commas only if there are 5 or more digits when expressing numbers. E.g. Platelets 250,000 and WBC 4000.
• Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration.
• Substitute a hyphen for the word "to". John was supposed to take 1-2 tablets of Naprosyn every 4-6 hours p.r.n. but he misunderstood and took five of them at a time.
• Leave a space between numerals and measurements unless they form a compound modifier. Eg. It is 10 cm below the popliteal fossa. A 4-cm melanocytic nevi was removed. A 5 x 4-mm lesion from the breast was resected.
• By default, 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. She has three cats, all of which died last summer. Around 8 keratotic plaques were removed.
• Do not start a sentence using a number. Spell out the number or recast the sentence. Eg. When it dictated as “3 milligrams of Diazepam was administered stat,” transcribe it as “Diazepam 3 mg was administered stat.” However, there is one exception to this when beginning the sentence with a date. Eg. 2005 has been a bad year for this patient.
Plurals - Do not use an apostrophe to form plural numbers.
Eg: 5 x 5s. She was in her late 30s or thirties. She was born in the 1950s.
Series of numbers - Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction.
• Example – She works at 2 places, gets paid for 3 jobs as she works 16 hours a day.
• Most common error is while transcribing “Diabetes type I and type II,” which is not correct. The correct version is Diabetes type 1 and 2. Similarly, “A II/VI holosystolic murmur was heard” is wrong. The correct way of transcribing is “A 2/6 holosystolic murmur was heard.”
• Many a times it happens that the figures get jumbled up, or rather two different series of numbers are and measurements are present in the same sentence. So to avoid confusion, it is better to transcribe one in figures and spell out the other. Eg. The Apgar scores were 6 and 8 at one and five minutes.
Time Examples
• 4:30 a.m. - morning
• 7:30 p.m. - evening
• noon, not 12:00 noon
• midnight, not 12:00 midnight or 12 'o'clock or 12:00 p.m.
“Space Usage”
Do not Type a Space
• Between any word and the punctuation following it.
• Between the number and the colon used to indicate a dilute solution or ratio.
• 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
• 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
Do 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(times or multiplication sign) in an expression of dimension, e.g. 4 x 4, alert and oriented x3.
“Get your Measurements right”
• Use F for Fahrenheit if it is accompanied by the symbol for degree, as in-his temperature was recorded as 101.6°F
• However, spell out Fahrenheit if you wish to take the pain of spelling of the degree out-101.6 degrees Fahrenheit (but not generally advisable as it lengthens the text.)
• Similarly use C for Celsius if accompanied by the symbol for degree-35.3°C and spell out Celsius if degree is spelled out. 35.3 degrees Celsius.
• Spell out all non-metric measurements. Feet, inches, pounds, ounces, yards with few exceptions as in “tsp for teaspoon” and “tbsp for tablespoon.”
• By default abbreviate all metric measurements. Write cm for centimeter, similarly mm for millimeter and so forth. There are some abbreviations for non-metric measurements too.
• 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
It is customary to abbreviate units of measure when accompanied by numerals, as using full form does not look good for it increases the text length.
Eg: 140/80 milligram of mercury - 140/80 mmHg. Also do not leave space between mm & Hg.
1.5 centimeters square -0.8 sq cm
4.2.0 liters per minute-3.0 L/min (L is abb for liters and should be written in Capital letters while milliliter is written as ml.)
8.5 grams percent of hemoglobin-8.5 gm% (no space to be used between gm and % as advised
earlier).
Use Symbols when you can’t text
Use symbols when they are used with numbers
Eg. 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
“Capitalize when lower is ruled out”
Capitalize abbreviations when the words they represent are capitalized
Capitalize the first word following a colon if it begins a complete sentence or is part of an outline entry
Capitalize most abbreviations of English words
Capitalize the first letter of chemical elements
Capitalize the names of the days of the week, months, holidays, historic events and religious festivals
Capitalize the names of specific departments or sections in the institution only when the institution name is included
Capitalize the names of diseases that include proper nouns, eponyms or genus names
Capitalize the trade or brand names of drugs
Capitalize a quote when it is a complete sentence
Capitalize the names of races, peoples, religions and languages. Eg African-American female, Black man.
Do not capitalize the spelled out names of the chemical elements
Do not capitalize the seasons of the year
Do not capitalize the common names of diseases
Do not capitalize the names of viruses unless they include a proper noun
Do not capitalize generic drug names
Do not capitalize the common noun following the brand name. Example - Tylenol tablets
Do not capitalize the names of medical or surgical specialties
Do not capitalize designations based on skin color, like "a tall white man."
“The prodigy of Hyphenation”
Use of hyphenation has been always a big headache while transcribing. It is difficult to remember which words are to be hyphenated and which not. However, in general terms, all those words, which are commonly used are generally not hyphenated. Besides below is a list of those words starting with these prefixes that do not require the use of hyphen:
ante Antepartum
anti antihypertensive
bi bibasilar
co cooperative
contra contraindicated
de defibrillated
extra extrapyramidal
infra infratemporal
inter intervertebral
intra intramammary
micro microglossia
mid midpole
non Noninflammatory
over Overprotective
pre preoperative
post postvoid
pro proactive
pseudo pseudomembranous
re reevaluation
semi semicircular
sub sublingual
super superannuated
supra supratentorial
trans transesophageal
ultra ultraviolet
un unintentional
under undernutrition
weight Weightloss
Always use a hyphen when compounded with the prefix self.
Example - self-administered, self-monitored.
IMP: Many a times, there may be altogether different meanings of a non-hyphenated word depending on sentence structure for clarification.
Cancer Classifications
Stage and grade - do not capitalize either one if it does not begin a sentence.
Use Roman numerals for cancer stages-stage I
Use Arabic numerals for cancer grades-grade 4
Eg: stage IIIA, stage IIIB, grade 3.
The most difficult task or rather the biggest confusion occurs while writing numbers. Here is a list of some Dos and Don’ts.
“Playing with Numbers”
• Always spell out whole numbers zero through nine and use numerals for 10 and above. Eg. This nine-year-old boy comes for a followup visit.
• Use numerals to express size and measurements.
• Use numerals for every sort of measurement. Centimeters, millimeters, liters, etc.
• Use numerals in all expressions pertaining to drugs - this includes strength, dosage and directions. Eg. Tamoxifen 20 mg daily, or Xeloda 1000 mg on days 2-5.
• Spell out fractions and hyphenate them when standing alone. Eg: She drank one-half liter of Ensure.
• Use numerals to express mixed fractions. 1½ months.
• Use commas only if there are 5 or more digits when expressing numbers. E.g. Platelets 250,000 and WBC 4000.
• Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration.
• Substitute a hyphen for the word "to". John was supposed to take 1-2 tablets of Naprosyn every 4-6 hours p.r.n. but he misunderstood and took five of them at a time.
• Leave a space between numerals and measurements unless they form a compound modifier. Eg. It is 10 cm below the popliteal fossa. A 4-cm melanocytic nevi was removed. A 5 x 4-mm lesion from the breast was resected.
• By default, 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. She has three cats, all of which died last summer. Around 8 keratotic plaques were removed.
• Do not start a sentence using a number. Spell out the number or recast the sentence. Eg. When it dictated as “3 milligrams of Diazepam was administered stat,” transcribe it as “Diazepam 3 mg was administered stat.” However, there is one exception to this when beginning the sentence with a date. Eg. 2005 has been a bad year for this patient.
Plurals - Do not use an apostrophe to form plural numbers.
Eg: 5 x 5s. She was in her late 30s or thirties. She was born in the 1950s.
Series of numbers - Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction.
• Example – She works at 2 places, gets paid for 3 jobs as she works 16 hours a day.
• Most common error is while transcribing “Diabetes type I and type II,” which is not correct. The correct version is Diabetes type 1 and 2. Similarly, “A II/VI holosystolic murmur was heard” is wrong. The correct way of transcribing is “A 2/6 holosystolic murmur was heard.”
• Many a times it happens that the figures get jumbled up, or rather two different series of numbers are and measurements are present in the same sentence. So to avoid confusion, it is better to transcribe one in figures and spell out the other. Eg. The Apgar scores were 6 and 8 at one and five minutes.
Time Examples
• 4:30 a.m. - morning
• 7:30 p.m. - evening
• noon, not 12:00 noon
• midnight, not 12:00 midnight or 12 'o'clock or 12:00 p.m.
“Space Usage”
Do not Type a Space
• Between any word and the punctuation following it.
• Between the number and the colon used to indicate a dilute solution or ratio.
• 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
• 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
Do 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(times or multiplication sign) in an expression of dimension, e.g. 4 x 4, alert and oriented x3.
“Get your Measurements right”
• Use F for Fahrenheit if it is accompanied by the symbol for degree, as in-his temperature was recorded as 101.6°F
• However, spell out Fahrenheit if you wish to take the pain of spelling of the degree out-101.6 degrees Fahrenheit (but not generally advisable as it lengthens the text.)
• Similarly use C for Celsius if accompanied by the symbol for degree-35.3°C and spell out Celsius if degree is spelled out. 35.3 degrees Celsius.
• Spell out all non-metric measurements. Feet, inches, pounds, ounces, yards with few exceptions as in “tsp for teaspoon” and “tbsp for tablespoon.”
• By default abbreviate all metric measurements. Write cm for centimeter, similarly mm for millimeter and so forth. There are some abbreviations for non-metric measurements too.
• 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
It is customary to abbreviate units of measure when accompanied by numerals, as using full form does not look good for it increases the text length.
Eg: 140/80 milligram of mercury - 140/80 mmHg. Also do not leave space between mm & Hg.
1.5 centimeters square -0.8 sq cm
4.2.0 liters per minute-3.0 L/min (L is abb for liters and should be written in Capital letters while milliliter is written as ml.)
8.5 grams percent of hemoglobin-8.5 gm% (no space to be used between gm and % as advised
earlier).
Use Symbols when you can’t text
Use symbols when they are used with numbers
Eg. 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
“Capitalize when lower is ruled out”
Capitalize abbreviations when the words they represent are capitalized
Capitalize the first word following a colon if it begins a complete sentence or is part of an outline entry
Capitalize most abbreviations of English words
Capitalize the first letter of chemical elements
Capitalize the names of the days of the week, months, holidays, historic events and religious festivals
Capitalize the names of specific departments or sections in the institution only when the institution name is included
Capitalize the names of diseases that include proper nouns, eponyms or genus names
Capitalize the trade or brand names of drugs
Capitalize a quote when it is a complete sentence
Capitalize the names of races, peoples, religions and languages. Eg African-American female, Black man.
Do not capitalize the spelled out names of the chemical elements
Do not capitalize the seasons of the year
Do not capitalize the common names of diseases
Do not capitalize the names of viruses unless they include a proper noun
Do not capitalize generic drug names
Do not capitalize the common noun following the brand name. Example - Tylenol tablets
Do not capitalize the names of medical or surgical specialties
Do not capitalize designations based on skin color, like "a tall white man."
“The prodigy of Hyphenation”
Use of hyphenation has been always a big headache while transcribing. It is difficult to remember which words are to be hyphenated and which not. However, in general terms, all those words, which are commonly used are generally not hyphenated. Besides below is a list of those words starting with these prefixes that do not require the use of hyphen:
ante Antepartum
anti antihypertensive
bi bibasilar
co cooperative
contra contraindicated
de defibrillated
extra extrapyramidal
infra infratemporal
inter intervertebral
intra intramammary
micro microglossia
mid midpole
non Noninflammatory
over Overprotective
pre preoperative
post postvoid
pro proactive
pseudo pseudomembranous
re reevaluation
semi semicircular
sub sublingual
super superannuated
supra supratentorial
trans transesophageal
ultra ultraviolet
un unintentional
under undernutrition
weight Weightloss
Always use a hyphen when compounded with the prefix self.
Example - self-administered, self-monitored.
IMP: Many a times, there may be altogether different meanings of a non-hyphenated word depending on sentence structure for clarification.
Cancer Classifications
Stage and grade - do not capitalize either one if it does not begin a sentence.
Use Roman numerals for cancer stages-stage I
Use Arabic numerals for cancer grades-grade 4
Eg: stage IIIA, stage IIIB, grade 3.
VIRGULE
A virgule is a punctuation mark “/”. It is also called a diagonal, separatrix, shilling mark,stroke, slant, or forward slash.
• In dates, the month, date, and year are separated by virgule, mostly in demographics.For example:
ADMISSION DATE: 01/01/2006 (MM/DD/YYYY)
DATE TRANSCRIBED: 01/02/2006 (no space before or after virgule)
• Sometimes a virgule is used to separate two terms to give choice between two entities.
For example:
The patient will be seen by his neurologist and/or psychiatrist.
• The virgule is also used to separate the numerator and denominator in fractions.
For example: 4/10
The wound measured approximately 2-1/4 inch.
• In numeral expressions, virgule is also used to express “over”.
For example:
The strength was 3/5 in all 4 extremities. (Transcribed)
The strength was three over five in all four extremities. (Dictated)
Similarly,
There was a grade 3/6 systolic ejection murmur over the precordium. (Transcribed)
There was grade three over six systolic ejection murmur over the precordium. (Dictated)
• A virgule is used to represent the word “per” when both entities are units of measure
and have a numeric quantity with them.
For example:
10 gm per liter (Dictated)
10 gm/L (Transcribed)
• A virgule is used to express terms having duality but referring to the same entity.
For example:
The patient will be seen by his hematologist/oncologist.
Transcribing percentages
The symbol for percent is % and it is used extensively in transcription . There are certain guidelines for use of this symbol though not very different from what we are usually used to.
The symbol % is used immediately following the Arabic numeral if it occurs in between the sentence.
For example: The ejection fraction was 40%.
If the sentence starts with the percentage, both the numeral and the symbol have to be spelled out.
For example: Forty percent ejection fraction is too great a risk for a patient with respiratory disorder.
When describing the range of percentages, the % symbol is to be used with each value.
For example: The carotid Doppler ultrasound showed 40% to 50% proximal stenosis.
It is wrong to transcribe it as 40 to 50% proximal stenosis.
If the percentage value is less than 1, 0 has to be placed before the decimal point.
For example: 0.5% Xylocaine is correct while .5% Xylocaine is wrong.
When the percentage value is a whole number, there is no need to add decimal or 0 after it.
For example: 20% of red blood cells showed rings and not 20.0% of red …
The symbol % is used immediately following the Arabic numeral if it occurs in between the sentence.
For example: The ejection fraction was 40%.
If the sentence starts with the percentage, both the numeral and the symbol have to be spelled out.
For example: Forty percent ejection fraction is too great a risk for a patient with respiratory disorder.
When describing the range of percentages, the % symbol is to be used with each value.
For example: The carotid Doppler ultrasound showed 40% to 50% proximal stenosis.
It is wrong to transcribe it as 40 to 50% proximal stenosis.
If the percentage value is less than 1, 0 has to be placed before the decimal point.
For example: 0.5% Xylocaine is correct while .5% Xylocaine is wrong.
When the percentage value is a whole number, there is no need to add decimal or 0 after it.
For example: 20% of red blood cells showed rings and not 20.0% of red …
Transcribing suture sizes in Transcription
The two most commonly used systems for suture sizes are:
USP system.
Brown and Sharp gauge.
USP system stands for United States Pharmacopeia System. This system classifies sizes of all types of suture materials. The start sizes range from 11-0, which is the smallest size to 7, which is the largest size.
For eg size 9-0 stands for 9 0's in a row, 000000000. Since this is too cumbersome to write, it is transcribed as 9-0, where 9 is for the number of zeros, followed by a hyphen, followed by the digit "0" without a space. Similarly, 000 will be 3-0 and 0000 will be 4-0. Sizes greater than 0 are expressed by whole numbers.
A symbol # is placed before the suture size while transcribing with any space in between.
For example:
Number three 0 Dacron is to be transcribed as "#3-0 Dacron."
Number two Prolene is transcribed as "#2 Prolene."
Brown and Sharp Gauge: This system is meant for expressing stainless suture steel sutures only. Here, whole numbers from 40 through 20 are used to specify the size in ascending amount wherein 40 is the smallest size and 20 is the largest. As mentioned before, symbol # is used if the word number is dictated before suture size.
For example:
Number thirty stainless steel wire is transcribed as "#30 stainless steel wire."
USP system.
Brown and Sharp gauge.
USP system stands for United States Pharmacopeia System. This system classifies sizes of all types of suture materials. The start sizes range from 11-0, which is the smallest size to 7, which is the largest size.
For eg size 9-0 stands for 9 0's in a row, 000000000. Since this is too cumbersome to write, it is transcribed as 9-0, where 9 is for the number of zeros, followed by a hyphen, followed by the digit "0" without a space. Similarly, 000 will be 3-0 and 0000 will be 4-0. Sizes greater than 0 are expressed by whole numbers.
A symbol # is placed before the suture size while transcribing with any space in between.
For example:
Number three 0 Dacron is to be transcribed as "#3-0 Dacron."
Number two Prolene is transcribed as "#2 Prolene."
Brown and Sharp Gauge: This system is meant for expressing stainless suture steel sutures only. Here, whole numbers from 40 through 20 are used to specify the size in ascending amount wherein 40 is the smallest size and 20 is the largest. As mentioned before, symbol # is used if the word number is dictated before suture size.
For example:
Number thirty stainless steel wire is transcribed as "#30 stainless steel wire."
SI UNITS
The international system of units consists of a set of units together with a set of prefixes. The units of SI can be divided into two subsets. There are the seven base units. Each of these base units are dimensionally independent. From these seven base units several other units are derived.
SI base units
SI writing style
• Symbols are written in lower case, except for symbols derived from the name of a person. The one exception is the liter, whose original symbol "l" is dangerously similar to the numeral "1". The NIST recommends that "L" be used instead, a usage, which is common in the U.S., Canada and Australia, and has been accepted as an alternative by the CGPM.
• Symbols are written without grammatical markers when used with singular numerals: i.e. "25 kg", not "25 kgs".
• Symbols do not have an appended period (.) unless at the end of a sentence.
• It is preferable to write symbols in upright Roman type (m for meters, L for liters), so as to differentiate from the italic type used for mathematical variables (m for mass, l for length).
• A space should separate the number and the symbol, e.g. "2.21 kg", "7.3×102 m2."
• Symbols formed by division of two units are joined with a virgule (/).
• For example, the "metre per second" is written as "m/s."
Spelling variations
• Several nations, notably the United States, typically use the spellings 'meter' and 'liter' instead of 'metre' and 'litre' in keeping with standard American English spelling.
• In addition, the official US spelling for the SI prefix 'deca' is 'deka'.
• The unit 'gram' is also sometimes spelled 'gramme' in English-speaking countries other than the United States, though that is an older spelling and its use is declining.
SI base units
Name-Symbol-QuantityA prefix may be added to units to produce a multiple of the original unit. All multiples are integer powers of ten. For example, kilo- denotes a multiple of a thousand and millidenotes a multiple of a thousandth hence there are one thousand millimeters to the metre and one thousand meters to the kilometer.
kilogram-kg-Mass
second-s-Time
metre-m- Length
ampere-A-Electrical current
kelvin-K-Temperature
mole-mol-Amount of substance
candela-cd-Luminous intensity
SI writing style
• Symbols are written in lower case, except for symbols derived from the name of a person. The one exception is the liter, whose original symbol "l" is dangerously similar to the numeral "1". The NIST recommends that "L" be used instead, a usage, which is common in the U.S., Canada and Australia, and has been accepted as an alternative by the CGPM.
• Symbols are written without grammatical markers when used with singular numerals: i.e. "25 kg", not "25 kgs".
• Symbols do not have an appended period (.) unless at the end of a sentence.
• It is preferable to write symbols in upright Roman type (m for meters, L for liters), so as to differentiate from the italic type used for mathematical variables (m for mass, l for length).
• A space should separate the number and the symbol, e.g. "2.21 kg", "7.3×102 m2."
• Symbols formed by division of two units are joined with a virgule (/).
• For example, the "metre per second" is written as "m/s."
Spelling variations
• Several nations, notably the United States, typically use the spellings 'meter' and 'liter' instead of 'metre' and 'litre' in keeping with standard American English spelling.
• In addition, the official US spelling for the SI prefix 'deca' is 'deka'.
• The unit 'gram' is also sometimes spelled 'gramme' in English-speaking countries other than the United States, though that is an older spelling and its use is declining.
Plurals
Plural means more than one and are usually made with the addition of "s" but in transcription there are certain guidelines to be followed.
When making plurals of upper cased abbreviations, lower cased 's' is added without apostrophe.
For example: WBCs, EKGs
The same is not true for lower cased abbreviations. Here an apostrophe is followed by lower cased 's.'
For example: rbc's
In case of brief forms, 's' is used without an apostrophe.
For example: exams, labs, segs, monos
In case of numbers, plurals are made by adding 's' only without any apostrophe, except in case of single digit number where apostrophe and 's' are used.
For example:
His pain scores were mostly 5's and 7's out of 10 on exam.
His mother died in her 60s.
However, no ‘s’ is used when making the plural of units of measure. Their singular and plural forms are the same. Therefore, 20 mgs is wrong.
For example: The incision was 10 cm long and not 10 cms long.
Plural of eponyms is made by adding 's' without apostrophe.
For example: Tinels were positive bilaterally.
Exceptions: Some words like biceps, triceps, forceps, series are always used in this same form whether singular or plural.
For more examples and information, please refer to the English section.
When making plurals of upper cased abbreviations, lower cased 's' is added without apostrophe.
For example: WBCs, EKGs
The same is not true for lower cased abbreviations. Here an apostrophe is followed by lower cased 's.'
For example: rbc's
In case of brief forms, 's' is used without an apostrophe.
For example: exams, labs, segs, monos
In case of numbers, plurals are made by adding 's' only without any apostrophe, except in case of single digit number where apostrophe and 's' are used.
For example:
His pain scores were mostly 5's and 7's out of 10 on exam.
His mother died in her 60s.
However, no ‘s’ is used when making the plural of units of measure. Their singular and plural forms are the same. Therefore, 20 mgs is wrong.
For example: The incision was 10 cm long and not 10 cms long.
Plural of eponyms is made by adding 's' without apostrophe.
For example: Tinels were positive bilaterally.
Exceptions: Some words like biceps, triceps, forceps, series are always used in this same form whether singular or plural.
For more examples and information, please refer to the English section.
Obstetrics Terminology
Obstetrics is that specialty of medicine, which is concerned with the care of women during the period of pregnancy, parturition, and delivery. The obstetrical history of a patient is put in abbreviated form with the use of GPA terminology, where in the GPA stands for G-gravid, P-para, and A-abortus.
The alphabets G, P, A along with Arabic numerals are used to describe the obstetric history of patient. If the patient is gravida 2, it is transcribed as G2 and similarly if the patient has aborted once, it is transcribed as 1. Thus, for a patient who is gravida 3, para 2 and aborted 1, the GPA is given as G3, P2, A1. The G, P, A are separated by commas and no space is left between the alphabet and Arabic numeral.
However, one can always spell out the GPA terms instead of writing in abbreviated form. So when these terms are spelled out, a space is given between the terms and the Arabic numeral.
For example: gravida 3, para 2, abortus 1.
How to transcribe, abbreviated or spell it out? Well, the golden rule is to transcribed Ad verbatim. If dictated G2, transcribe as G2 and if spelled out the gravida 2.
Station: Station denotes the degree of descent of the presenting part of the fetus through the maternal pelvis during the period of delivery. The base is taken at the point through ischial spine through which an imaginary plane is drawn and is designated as 0. Presentation of the fetus above or below this plane is then given reference values from -5 to +5, the distance above or below this is mentioned from -5 to +5 respectively in cm.
It is transcribed by using a + or - sign preceding the numeral 1 to 5 without any space in between.
For example: The cervix was 5 cm dilated at +4 station.
The alphabets G, P, A along with Arabic numerals are used to describe the obstetric history of patient. If the patient is gravida 2, it is transcribed as G2 and similarly if the patient has aborted once, it is transcribed as 1. Thus, for a patient who is gravida 3, para 2 and aborted 1, the GPA is given as G3, P2, A1. The G, P, A are separated by commas and no space is left between the alphabet and Arabic numeral.
However, one can always spell out the GPA terms instead of writing in abbreviated form. So when these terms are spelled out, a space is given between the terms and the Arabic numeral.
For example: gravida 3, para 2, abortus 1.
How to transcribe, abbreviated or spell it out? Well, the golden rule is to transcribed Ad verbatim. If dictated G2, transcribe as G2 and if spelled out the gravida 2.
Station: Station denotes the degree of descent of the presenting part of the fetus through the maternal pelvis during the period of delivery. The base is taken at the point through ischial spine through which an imaginary plane is drawn and is designated as 0. Presentation of the fetus above or below this plane is then given reference values from -5 to +5, the distance above or below this is mentioned from -5 to +5 respectively in cm.
It is transcribed by using a + or - sign preceding the numeral 1 to 5 without any space in between.
For example: The cervix was 5 cm dilated at +4 station.
Guidelines for transcribing numbers
There are two types of numerals, Arabic and Roman, which are used in medical transcription . Numbers denote quantities, ages, time and position in a series.
Arabic numerals are in all 10, which are 0,1,2,3,4,5,6,7,8,9.
Roman numerals are made of 7 letters, given below:
I 1
V 5
X 10
L 50
C 100
O 500
K 1000
Roman numerals are used to a lesser extent in transcription usually in staging of diseases, syndromes or the most common statement, for example: Cranial nerves II through XII are normal, Stage I disease.
Arabic numerals are widely used in transcription to denote ages, units of measure, dosages, vitals, lab values, and dimensions.
For example: Hemoglobin was 14.4, platelet count was 156,000, a 45-year-old male was seen today.
If a sentence begins with a number, the number has to be spelled out and/or if needed rephrase the sentence.
For example: "Twenty-two years ago, the patient had her last menstrual period." Or one can rephrase the sentence as "The patient had her last menstrual period 34 years ago."
Numbers used to represent position in a series are called ordinal numbers.
Ordinals from (1st) first to ninth (9th) are spelled out in report while ordinals greater than 9th are transcribed in figures like 12th, 21st. No periods or space is used with ordinals.
For example: The patient underwent his fourth cesarean section without any complications.
The obese female met with a severe accident on her 50th birthday.
Use of commas in Arabic numbers:
When a whole number has 5 or more digits, a comma should be sued to separate a group of 3 numerals, starting from the end of the number.
For example: White blood cell count was 45,700, platelet count was 290,000.
However, if the whole number comprises of 4 digits only, a comma should not be used.
For example: White count is 6400.
When two sets of interrelated numbers are used next to each other, generally the one dictated earlier should be spelled out one or rather any one of them can be spelled out depending on convenience.
For example: The subjects used for the experiment were fifteen 7-year-old boys.
The laceration was sutured with two 2-0 Vicryl sutures.
Use of hyphens in numbers:
Always hyphenate compound numbers from 21 through 99.
For example: fifty-five, sixty-six, eleven thousand five hundred forty-six
Always Hyphenate compound nouns which use numbers are prefix.
For example: 2-D echocardiogram
When numbers are used as compound modifiers with words, they should be hyphenated when they precede the noun. For example:
An 18-day cycle, a 3-cm incision
Forming Plurals in numbers:
To form plurals, apostrophe "s"is used with single digit number and lower cased s is used with 2 or more than 2 i.e. multiple digit number.
For example:
He died in his 50s. The patient was born in 1950s.
He required atleast four 6’s to reach to his century.
Numbers used in proper nouns are transcribed the way they are used in the proper noun.
For example: figure-of-eight suture and not figure of 8 suture.
Arabic numerals are in all 10, which are 0,1,2,3,4,5,6,7,8,9.
Roman numerals are made of 7 letters, given below:
I 1
V 5
X 10
L 50
C 100
O 500
K 1000
Roman numerals are used to a lesser extent in transcription usually in staging of diseases, syndromes or the most common statement, for example: Cranial nerves II through XII are normal, Stage I disease.
Arabic numerals are widely used in transcription to denote ages, units of measure, dosages, vitals, lab values, and dimensions.
For example: Hemoglobin was 14.4, platelet count was 156,000, a 45-year-old male was seen today.
If a sentence begins with a number, the number has to be spelled out and/or if needed rephrase the sentence.
For example: "Twenty-two years ago, the patient had her last menstrual period." Or one can rephrase the sentence as "The patient had her last menstrual period 34 years ago."
Numbers used to represent position in a series are called ordinal numbers.
Ordinals from (1st) first to ninth (9th) are spelled out in report while ordinals greater than 9th are transcribed in figures like 12th, 21st. No periods or space is used with ordinals.
For example: The patient underwent his fourth cesarean section without any complications.
The obese female met with a severe accident on her 50th birthday.
Use of commas in Arabic numbers:
When a whole number has 5 or more digits, a comma should be sued to separate a group of 3 numerals, starting from the end of the number.
For example: White blood cell count was 45,700, platelet count was 290,000.
However, if the whole number comprises of 4 digits only, a comma should not be used.
For example: White count is 6400.
When two sets of interrelated numbers are used next to each other, generally the one dictated earlier should be spelled out one or rather any one of them can be spelled out depending on convenience.
For example: The subjects used for the experiment were fifteen 7-year-old boys.
The laceration was sutured with two 2-0 Vicryl sutures.
Use of hyphens in numbers:
Always hyphenate compound numbers from 21 through 99.
For example: fifty-five, sixty-six, eleven thousand five hundred forty-six
Always Hyphenate compound nouns which use numbers are prefix.
For example: 2-D echocardiogram
When numbers are used as compound modifiers with words, they should be hyphenated when they precede the noun. For example:
An 18-day cycle, a 3-cm incision
Forming Plurals in numbers:
To form plurals, apostrophe "s"is used with single digit number and lower cased s is used with 2 or more than 2 i.e. multiple digit number.
For example:
He died in his 50s. The patient was born in 1950s.
He required atleast four 6’s to reach to his century.
Numbers used in proper nouns are transcribed the way they are used in the proper noun.
For example: figure-of-eight suture and not figure of 8 suture.
Guidelines with BUILDING, STRUCTURE, AND ROOM NAMES
GUIDELINES WITH BUILDING, STRUCTURE, AND ROOM NAMES
• Proper names of buildings and structures should always be capitalized (initial letter in upper case).
For example: Kennedy House
• Words like building, center, and room should be capitalized only if they are an integral part of the proper name or accompany the name, otherwise not.
For example: Mercy Medical Center, Babylon Emergency Room
The patient was transferred immediately to Elmont Emergency Room.
• Common nouns designating rooms or units or centers should not ideally be capitalized unless preceded by a noun.
For example: The patient left the emergency room in good condition.
He was kept in the intensive care unit.
• Proper names of buildings and structures should always be capitalized (initial letter in upper case).
For example: Kennedy House
• Words like building, center, and room should be capitalized only if they are an integral part of the proper name or accompany the name, otherwise not.
For example: Mercy Medical Center, Babylon Emergency Room
The patient was transferred immediately to Elmont Emergency Room.
• Common nouns designating rooms or units or centers should not ideally be capitalized unless preceded by a noun.
For example: The patient left the emergency room in good condition.
He was kept in the intensive care unit.
Guidelines with Dates
• The ideal format for writing dates is in month, day, year format where the year is separated from month and day by a comma.
For example: The patient will undergo repair on January 9, 2006.
• However, when military date format is used, i.e. date, month, year, commas are not used to separate them.
For example: The patient underwent surgery on 12 December 2005.
• When the date comes in between the sentence, then the year has to be placed between a set of commas.
For example: On January 1, 2005, the patient expired.
• In transcription, the days of week from Sunday through Saturday are always capitalized.
For example: Thursday, Saturday
• Similarly, one needs to capitalize all the months in a year.
For example: January, February, March, April...
• Arabic numerals should always be used to indicate day of month as well as while transcribing year.
For example: January 20, 2006.
• When only month and year are given for a specific entity, no comma should be used to separate them.
For example: The patient was operated in March 2005.
Ordinal usage:
Ordinals find frequent use during transcription. They are to be used in cases when the day of the month precedes the month and it is also preceded by the year. They are not used in month, day, and year format. No commas are to be used when ordinals are used.
For example:
(Correct): On the 1st of January 2006, the soldier got promoted to major.
(Wrong way): On January 1st, 1980, the soldier got promoted to major.
Virgule Usage while transcribing dates:
During transcription, dates are to be transcribed in Arabic numerals in MM/DD/YYYY format separated by virgules (slash) especially while transcribing dictation dates, transcription dates, admission dates, discharge dates, visit dates. In such cases, months are not spelled out. Therefore, months are transcribed in Arabic numerals form 01 to 12 and dates from 01 to 31 and are transcribed in MM/DD/YYYY format separated by virgules.
For example:
(Dictated): ADMISSION DATE is first January 2006.
(Transcribed): ADMISSION DATE: 01/01/2006
For example: The patient will undergo repair on January 9, 2006.
• However, when military date format is used, i.e. date, month, year, commas are not used to separate them.
For example: The patient underwent surgery on 12 December 2005.
• When the date comes in between the sentence, then the year has to be placed between a set of commas.
For example: On January 1, 2005, the patient expired.
• In transcription, the days of week from Sunday through Saturday are always capitalized.
For example: Thursday, Saturday
• Similarly, one needs to capitalize all the months in a year.
For example: January, February, March, April...
• Arabic numerals should always be used to indicate day of month as well as while transcribing year.
For example: January 20, 2006.
• When only month and year are given for a specific entity, no comma should be used to separate them.
For example: The patient was operated in March 2005.
Ordinal usage:
Ordinals find frequent use during transcription. They are to be used in cases when the day of the month precedes the month and it is also preceded by the year. They are not used in month, day, and year format. No commas are to be used when ordinals are used.
For example:
(Correct): On the 1st of January 2006, the soldier got promoted to major.
(Wrong way): On January 1st, 1980, the soldier got promoted to major.
Virgule Usage while transcribing dates:
During transcription, dates are to be transcribed in Arabic numerals in MM/DD/YYYY format separated by virgules (slash) especially while transcribing dictation dates, transcription dates, admission dates, discharge dates, visit dates. In such cases, months are not spelled out. Therefore, months are transcribed in Arabic numerals form 01 to 12 and dates from 01 to 31 and are transcribed in MM/DD/YYYY format separated by virgules.
For example:
(Dictated): ADMISSION DATE is first January 2006.
(Transcribed): ADMISSION DATE: 01/01/2006
Guidelines with BLOOD PRESSURE
• Blood pressure is reported in millimeters of mercury (mmHg). But in transcription the doctor only dictates the values. In such scenario one should not use the units “mmHg”:
For example: The blood pressure is 120/80. (In this case, since the units are not dictated, they are not transcribed.)
• When the unit “millimeter of mercury (mmHg)” is dictated, it should be transcribed without a space.
For example: The blood pressure is 120/80 mmHg.
• A virgule is used to separate the systolic and diastolic readings of blood pressure. Usually the dictator dictates blood pressure as 120 over 80 and it is transcribed as 120/80.
• All the lab values are expressed in Arabic numerals. Remember never use commas to separate the lab value from its test. They are never to be separated.
For example: Correct: hematocrit 36.8, white count 4.8, platelets 240,000.
Incorrect: hematocrit, 36.8, white count, 4.8, platelets, 240,000.
• When a series of lab tests and their values are mentioned, the tests that are related to each other should be separated by commas and the tests not related to each other should be separated by periods.
For example: WBC 5.1, hemoglobin 11.2, hematocrit 33.8, platelet count 240,000.
Sodium 139, potassium 4.2, and bicarbonate 22.
• When there are internal commas in one entity then separate the series with semicolons.
For example: CBC showed WBC 5.1 with 51 segs, 9 bands, 31 lymphs, 11 monos, 4eos, 3basos; hemoglobin 11.2; hematocrit 33.8; and platelets 240,000.
For example: The blood pressure is 120/80. (In this case, since the units are not dictated, they are not transcribed.)
• When the unit “millimeter of mercury (mmHg)” is dictated, it should be transcribed without a space.
For example: The blood pressure is 120/80 mmHg.
• A virgule is used to separate the systolic and diastolic readings of blood pressure. Usually the dictator dictates blood pressure as 120 over 80 and it is transcribed as 120/80.
• All the lab values are expressed in Arabic numerals. Remember never use commas to separate the lab value from its test. They are never to be separated.
For example: Correct: hematocrit 36.8, white count 4.8, platelets 240,000.
Incorrect: hematocrit, 36.8, white count, 4.8, platelets, 240,000.
• When a series of lab tests and their values are mentioned, the tests that are related to each other should be separated by commas and the tests not related to each other should be separated by periods.
For example: WBC 5.1, hemoglobin 11.2, hematocrit 33.8, platelet count 240,000.
Sodium 139, potassium 4.2, and bicarbonate 22.
• When there are internal commas in one entity then separate the series with semicolons.
For example: CBC showed WBC 5.1 with 51 segs, 9 bands, 31 lymphs, 11 monos, 4eos, 3basos; hemoglobin 11.2; hematocrit 33.8; and platelets 240,000.
Guidelines with Blood Counts
Blood counts are very frequently encountered in medical reports and a proper and complete knowledge of it is a must for a good transcriptionist, so as not to end up in a big mistake making a mockery of it. The blood count is calculated based on number of blood cells in a cubic millimeter of blood.
Complete Blood Count (CBC):
The complete blood count consists of white blood cell count, red blood cell count, hemoglobin, hematocrit, platelet count, and differential blood count. Refer to the normal laboratory values section.
These are transcribed in Arabic numerals. There is no punctuation between the value and the particular entity of blood count.
For example: Hemoglobin 10.8
Differential Blood Count:
Differential blood count consists of the percentage of each type of white blood cell that makes the total white blood count. It includes polymorphonuclear neutrophils (polyps, PMNs, or segs), eosinophils (eos), basophils (basos), lymphocytes (lymphs), monocytes (monos), and band neutrophils (bands). They can be dictated either as percent or as number but in all circumstances their total should always come to 100. This important fact should always a good transcriptionist error-free while reporting blood counts.
Complete Blood Count (CBC):
The complete blood count consists of white blood cell count, red blood cell count, hemoglobin, hematocrit, platelet count, and differential blood count. Refer to the normal laboratory values section.
These are transcribed in Arabic numerals. There is no punctuation between the value and the particular entity of blood count.
For example: Hemoglobin 10.8
Differential Blood Count:
Differential blood count consists of the percentage of each type of white blood cell that makes the total white blood count. It includes polymorphonuclear neutrophils (polyps, PMNs, or segs), eosinophils (eos), basophils (basos), lymphocytes (lymphs), monocytes (monos), and band neutrophils (bands). They can be dictated either as percent or as number but in all circumstances their total should always come to 100. This important fact should always a good transcriptionist error-free while reporting blood counts.
Guidelines with Ages
• Arabic numerals are always used to express age.
For example: The patient is a l5-year-old male who ...
• If age comes at the beginning of the sentence, it should be reframed.
For example:
Dictated statement: 15-year-old female came with bruise to the knee.
Transcribed as: A 15-year-old female came with bruise to the knee.
• When age is preceded by a noun and is used as an adjective, it should be hyphenated.
For example: A 7-year-old boy (Remember there should be no space between the
hyphens.) Here boy is the noun with number of years as the adjective.
• So what happens when the age comes after a noun? In such phrases, the year is always in plural with addition of 's' and is written without use of hyphens and conversely when age precedes the noun as an adjectival phrase, year is singular with
out an 's'.
Here are the two examples again:
A 15-year-old female came with bruise to the knee.
This female who is 15 years old came with bruise to the knee.
• If age is expressed in fractions (like six and a half year old), then a virgule should be incorporated. It is used to express the fraction along with the whole number and joined to it with a hyphen online.
For example:
6-1/2-year-old patient is the correct way to transcribe.
• When age is referred to in decades, no apostrophe is used.
For example:
The patient's brother died in his 20s.
For example: The patient is a l5-year-old male who ...
• If age comes at the beginning of the sentence, it should be reframed.
For example:
Dictated statement: 15-year-old female came with bruise to the knee.
Transcribed as: A 15-year-old female came with bruise to the knee.
• When age is preceded by a noun and is used as an adjective, it should be hyphenated.
For example: A 7-year-old boy (Remember there should be no space between the
hyphens.) Here boy is the noun with number of years as the adjective.
• So what happens when the age comes after a noun? In such phrases, the year is always in plural with addition of 's' and is written without use of hyphens and conversely when age precedes the noun as an adjectival phrase, year is singular with
out an 's'.
Here are the two examples again:
A 15-year-old female came with bruise to the knee.
This female who is 15 years old came with bruise to the knee.
• If age is expressed in fractions (like six and a half year old), then a virgule should be incorporated. It is used to express the fraction along with the whole number and joined to it with a hyphen online.
For example:
6-1/2-year-old patient is the correct way to transcribe.
• When age is referred to in decades, no apostrophe is used.
For example:
The patient's brother died in his 20s.
Transcribing Globulins and Immunoglobulins
Globulin is one of the two types of serum proteins, the other being albumin. This generic term encompasses a heterogenous series of families of proteins, with larger molecules and less soluble in pure water than albumin, which migrate less than albumin during serum electrophoresis.
It is sometimes used synonymously with Globular protein. However, albumin is also a globular protein, but not a globulin. All other serum globular proteins are globulins.
Protein electrophoresis is used to categorize globulins into the following four categories:
The Greek letters used with globulin should be transcribed in plain English and abbreviation should generally not be used. For example: beta globulin or b-globulin. Both are correct. Similarly, alpha globulin or a-globulin is also correct.
If the globulin carries a numeral with it, it is transcribed after the translation for Greek word adjoined by a hyphen with the globulin following it. For example: beta-2 globulin, alpha-1 trypsinogen.
Immunoglobulins:
Immunoglobulins or Gamma globulins are a class of proteins in the blood, identified by their position after serum protein electrophoresis. The most significant gamma globulins are antibodies.
Globulins which act as antibodies are of five types Expressed as IgA, IgD, IgE, IgG, IgM. Upper case I, lower case g, for immunoglobulin (Ig) followed by upper-cased alphabet A, D, E, G, or M. For example: IgA, IgM, IgE.
It is sometimes used synonymously with Globular protein. However, albumin is also a globular protein, but not a globulin. All other serum globular proteins are globulins.
Protein electrophoresis is used to categorize globulins into the following four categories:
- Alpha 1 globulins
- Alpha 2 globulins
- Beta globulins
- Gamma globulins (immunoglobulins)
The Greek letters used with globulin should be transcribed in plain English and abbreviation should generally not be used. For example: beta globulin or b-globulin. Both are correct. Similarly, alpha globulin or a-globulin is also correct.
If the globulin carries a numeral with it, it is transcribed after the translation for Greek word adjoined by a hyphen with the globulin following it. For example: beta-2 globulin, alpha-1 trypsinogen.
Immunoglobulins:
Immunoglobulins or Gamma globulins are a class of proteins in the blood, identified by their position after serum protein electrophoresis. The most significant gamma globulins are antibodies.
Globulins which act as antibodies are of five types Expressed as IgA, IgD, IgE, IgG, IgM. Upper case I, lower case g, for immunoglobulin (Ig) followed by upper-cased alphabet A, D, E, G, or M. For example: IgA, IgM, IgE.
Geographic Names and Proper Names
Geographic Names
-Always capitalize the names of geographic divisions like mountains, rivers, islands, oceans, states, countries, towns, cities, continents, and streets.
For example: United States of America, Mount Everest, Tokyo, New York, Great Britain
- Capitalize common nouns only when they are a part of proper names, not when they stand alone.
For example:
River Ravi flows through India and Pakistan.
The ocean was quite dirty.
Though Niagara Falls is the most famous tourist attraction, the falls in Cherrapunji are extremely beautiful.
- The words, which are derived from geographic names but used to convey a special meaning, are not capitalized.
For example: plaster of paris, french fries
- If the name of a city precedes the name of the state or if name of a state precedes the name of a country in text, then separate the state and country from city and state respectively by commas.
For example:
The doctor lives in Babylon, New York.
His office is in San Jose, California.
- Proper adjectives and sociocultural derivatives from geographic names are capitalized.
For example: This Spanish-speaking lady comes from New York, This is an 81-year-old African-American lady
Proper Names
Names of a person, place, apartment, street, organization should always be capitalized. For example:
George Bush II
Lady Harding Hospital.
Common names, places, and things are not to be capitalized.
For example:
Novartis is a big pharmaceutical company
She owns her own cosmetic clinic
Columbia is a very famous university in Canada.
-Always capitalize the names of geographic divisions like mountains, rivers, islands, oceans, states, countries, towns, cities, continents, and streets.
For example: United States of America, Mount Everest, Tokyo, New York, Great Britain
- Capitalize common nouns only when they are a part of proper names, not when they stand alone.
For example:
River Ravi flows through India and Pakistan.
The ocean was quite dirty.
Though Niagara Falls is the most famous tourist attraction, the falls in Cherrapunji are extremely beautiful.
- The words, which are derived from geographic names but used to convey a special meaning, are not capitalized.
For example: plaster of paris, french fries
- If the name of a city precedes the name of the state or if name of a state precedes the name of a country in text, then separate the state and country from city and state respectively by commas.
For example:
The doctor lives in Babylon, New York.
His office is in San Jose, California.
- Proper adjectives and sociocultural derivatives from geographic names are capitalized.
For example: This Spanish-speaking lady comes from New York, This is an 81-year-old African-American lady
Proper Names
Names of a person, place, apartment, street, organization should always be capitalized. For example:
George Bush II
Lady Harding Hospital.
Common names, places, and things are not to be capitalized.
For example:
Novartis is a big pharmaceutical company
She owns her own cosmetic clinic
Columbia is a very famous university in Canada.
Fractions
• In common usage a fraction is any part of a unit. A fraction is a way of expressing a quantity based on an amount that is divided into a number of equal-sized parts. For example, each part of a cake split into four equal parts is called a quarter (and represented numerically as 1⁄4); two quarters is half the cake, and eight quarters would make two cakes.
Tips while transcribing Fractions:
• Fractions are to be spelled out when less than 1 and if it is not followed immediately by a noun.
For example: The specimen measured one-quarter of a pound.
• Fractions are to be spelled out if the sentence begins with them.
For example: One and a half years back, the patient had come to me.
• When the fraction precedes a noun, Arabic numeral should be used to transcribe it. Use a hyphen to join the fraction with the noun it modifies.
For example: A 1½-inch incision was made.
• Employ Arabic numerals for fractions in ages.
For example:
The patient is a 4-½ -years old.
This 5-½-year-old patient underwent bilateral hand surgery.
• If a fraction is dictated with SI units, convert it into decimals. However, with other
units of measure, fractions are used.
For example:
(Dictated): The lesion was three and a half cm in size.
(Transcribed): The lesion was 3.5 cm in size. (Correct) .
The lesion was 3-1/2 cm in size (Incorrect)
• Place a hyphen following the whole number and place the fraction on the same line if
there is no possibility of reducing size of fractions.
For example: A 4-l/2-year-old patient was brought to me for second opinion.
• In case of dimensions when using imperial units, always use numerals for fractions,
with a hyphen between the whole number and the fraction.
For example: The cyst measured 1-1/2 x 2-1/2 x 1 inch.
Tips while transcribing Fractions:
• Fractions are to be spelled out when less than 1 and if it is not followed immediately by a noun.
For example: The specimen measured one-quarter of a pound.
• Fractions are to be spelled out if the sentence begins with them.
For example: One and a half years back, the patient had come to me.
• When the fraction precedes a noun, Arabic numeral should be used to transcribe it. Use a hyphen to join the fraction with the noun it modifies.
For example: A 1½-inch incision was made.
• Employ Arabic numerals for fractions in ages.
For example:
The patient is a 4-½ -years old.
This 5-½-year-old patient underwent bilateral hand surgery.
• If a fraction is dictated with SI units, convert it into decimals. However, with other
units of measure, fractions are used.
For example:
(Dictated): The lesion was three and a half cm in size.
(Transcribed): The lesion was 3.5 cm in size. (Correct) .
The lesion was 3-1/2 cm in size (Incorrect)
• Place a hyphen following the whole number and place the fraction on the same line if
there is no possibility of reducing size of fractions.
For example: A 4-l/2-year-old patient was brought to me for second opinion.
• In case of dimensions when using imperial units, always use numerals for fractions,
with a hyphen between the whole number and the fraction.
For example: The cyst measured 1-1/2 x 2-1/2 x 1 inch.
Format for Letters, Addressing Names, and Salutations
Format for Letters, Addressing Names, Salutations and Attention line
One of the most error-prone zone in transcription is while transcribing letters. Since letters are usually addressed to doctors who are themselves highly proficient in their profession, any error in the letter can make them a little annoyed. So take utmost care during transcribing letters.
The address is usually typed with a left margin alignment and is begun leaving a space of 3 to 4 lines below the date of the letter. However, this can vary depending on letter size and customer specifications.
Guidelines for Addressing Names of Persons
Always a courtesy title like Mr., Mrs., Ms. or a professional title as Dr. is added to a name. If one does not know whether the person is a man or a woman, do not use any title. Similarly, the title "Ms." should be used when one does not know which title is to be used for a woman. In cases, when the degree of the person addressed is know, the degree should be preferred over the title. Both the degree and title must never be used together.
For example:
Incorrect: Correct
Dr. James F. Bethpage, MD Dr. James F. Bethpage or James F. Bethpage, MD
Dr. Linda McKinley, DO Dr. Linda McKinley or Linda McKinley, DO
Mr. Shawn Patrice, Phd Mr. Shawn Patrice or Shawn Patrice, Phd
Always use the complete name of a person if known with the courtesy title
For example:
Dr. Allen Markowitz
Professor John P. Doyle
Drs. Pugh, Hyle and McCArtney
Captain Copper W. Wright
The name of the person should never be abbreviated when addressing him or her.
For example:
Patrick K. McCartney, MD is the right way to address and not Pat K. McCartney, MD
When a person has two or more degrees, they are to be separated by a comma in between them and should be placed in order of increasing distinction and recognition.
Example: Lee J. Hills, MMS, MD, FACOG and not as Lee J. Hills, FACOG, MD, MS
Sometimes, the names are written in reverse order with the last name first and first name last. In such cases, the parts of the name are to be separated by comma. Usually a comma is placed after the last name and before the degree if it needs to be mentioned.
For example: Lee J. Hills, MD can also be written as Hills, Lee J., MD (see the comma usage)
However, one cannot address a person with the title in the reverse order. For example, it is wrong to write Dr. Hills, Lee J. So the correct way of transcribing is Hills, Lee J., MD
Guidelines for Addressing Names of Firms:
When transcribing name of the firm, always copy as it is printed on the company’s letterhead, website or as mentioned in the directory. Under all circumstances, the abbreviations and punctations of the firm’s name are not to be changed.
For example:
Queens-Long Island Medical Group.
Beth-Israel General Hospital
Copper & Raunchy Pathology Lab.
Schwanam, Haslip and Kimbrell Dental Clinic
Guidelines for Addressing Persons with Business Titles:
While writing official letters or addressing people of higher business profile, mentioning the business title looks more professional and respectful. When a business title accompanies any name, it is usually written last after the degree or after the name separated by a comma but if the space does not permit it to be on the same line, it can be written on the next line without the use of the comma.
For example:
Levlin K. Mirchandani, MS, Medical Director
Kevin Kasparov, LLB
Chief of Sales
Benjamin F. Camille, MD, MS
Head of Forensic Sciences
Guidelines while writing address
The address is to be written immediately flushed to the next line after the name of the person or the firm.
Usually the address starts with street name, apartment or suite number, city, state and Zip code. One should not abbreviate North, South, West, Street, Avenue, Boulevard and even Apartment except when the address line is getting too big. Usually, it looks nice to have the whole address mentioned in two or three lines. The city name is always to be spelled out and separated with comma from the State. The state name can be abbreviated or can be spelled out and is separated from the zip code with one or two space but no comma or dash. There is no need to put comma or period at the end of the address line. Comma should only be used to separate the street and suite names or as in city and state name.
Finally, it is better to copy the address as mentioned on the letter head, website or as approved by the USPS.
For example:
Kathy Suekat, MD
One Nameoke Street, Suite QE
Far Rockaway, New York 11432
(One should always be spelled out when used in building, street, suite or apartment number)
Elaine Markowitz, MD
1465 Broadway,
Hewlett, New York 11551
Susan B. Johnson, LLB
Apartment 34,
1782 Collinmore Street
Luxemborg, MA 13456
Napil B. Pakisha, MD
PO Box 1934
Maples, CA 44560
Forms of Salutations:
After finishing with the address line starts the most important part of a letter i.e. salutation. This is a highly important protocol when starting the letter. Usually, it’s easier to write the salutation when a person addressed is single but becomes more difficult and more error prone, while addressing two or more people.
The salutation starts after leaving two blank lines after the address line and is to be followed by a colon or a comma as felt appropriate.
Here are some common ways of writing salutation:
Dear Paul: or Dear Paul,
Dear Dr. Ben: or Dear Doctor Ben:
Dear Drs. Mike and Lee or Dear Dr. Mike and Dr. Lee:
Dear Linda and Betty: or Dear Linda and Betty,
Dear Mrs. Kathy and Ms. Brenda:
Some examples for married couples.
Dear Mr. and Mrs. Bond:
Dear Professor Bill and Professor Kavita:
Dear Dr. Wu and Mrs. Cathy:
Dear Captain Pat and Professor Rina:
Dear Mr. Bright and Dr. Bright:
Some examples for unmarried couples associated with business or work purposes.
Dear Professor Paul and Mrs. Wright:
Dear Dr. Mills and Dr. Hilton:
Dear William and Nancy:
When addressing a large group together, use the standard salutation format.
Ladies and Gentleman:
Dear Professor McCarthy et al: (One can also use the name of the most senior person of the firm followed by et all, meaning all others.)
Guidelines to Use Attention Line:
Sometimes it becomes necessary to use the Attention line instead of going straight to salutation. When the attention line is used, it should be typed two blank spaces after the last address line flushed with the left margin. It should be written in full and usually capital form or even the first letter in caps would do but it is never to be abbreviated.
Example:
Attention: Mrs. Nancy P. Blake or ATTENTION: Mrs. Nancy P. Blake
If the title is going long, one can accommodate on the second line. For example:
Attention: Mrs. Nancy P. Blake
Purchasing officer
Always take care that the second line should start at the same point where the name of the person starts. This maintains clarity, visibility and neatness. It is wrong to use abbreviated form of Attention as Attn.
It is always debatable to use both the attention line and the salutation line. Some would like to use only the salutation format without any attention line while some would prefer to use the attention line. In any case, the salutation should always be in accordance with the attention line.
For example:
Attention: Mrs. Nancy P. Blake
Dear Madam,
This is the most frequent format used rather than using Dear Mrs. Nancy as mentioning the same name twice is improper.
So the start of a letter would look as follows:
May 28, 2006
Bethnovar Medical Clinic
1024 Nameoke Street, Suite 2B
Far Rockaway, New York 11621
Attention: Mrs. Nancy P. Blake
Dear Madam:
One of the most error-prone zone in transcription is while transcribing letters. Since letters are usually addressed to doctors who are themselves highly proficient in their profession, any error in the letter can make them a little annoyed. So take utmost care during transcribing letters.
The address is usually typed with a left margin alignment and is begun leaving a space of 3 to 4 lines below the date of the letter. However, this can vary depending on letter size and customer specifications.
Guidelines for Addressing Names of Persons
Always a courtesy title like Mr., Mrs., Ms. or a professional title as Dr. is added to a name. If one does not know whether the person is a man or a woman, do not use any title. Similarly, the title "Ms." should be used when one does not know which title is to be used for a woman. In cases, when the degree of the person addressed is know, the degree should be preferred over the title. Both the degree and title must never be used together.
For example:
Incorrect: Correct
Dr. James F. Bethpage, MD Dr. James F. Bethpage or James F. Bethpage, MD
Dr. Linda McKinley, DO Dr. Linda McKinley or Linda McKinley, DO
Mr. Shawn Patrice, Phd Mr. Shawn Patrice or Shawn Patrice, Phd
Always use the complete name of a person if known with the courtesy title
For example:
Dr. Allen Markowitz
Professor John P. Doyle
Drs. Pugh, Hyle and McCArtney
Captain Copper W. Wright
The name of the person should never be abbreviated when addressing him or her.
For example:
Patrick K. McCartney, MD is the right way to address and not Pat K. McCartney, MD
When a person has two or more degrees, they are to be separated by a comma in between them and should be placed in order of increasing distinction and recognition.
Example: Lee J. Hills, MMS, MD, FACOG and not as Lee J. Hills, FACOG, MD, MS
Sometimes, the names are written in reverse order with the last name first and first name last. In such cases, the parts of the name are to be separated by comma. Usually a comma is placed after the last name and before the degree if it needs to be mentioned.
For example: Lee J. Hills, MD can also be written as Hills, Lee J., MD (see the comma usage)
However, one cannot address a person with the title in the reverse order. For example, it is wrong to write Dr. Hills, Lee J. So the correct way of transcribing is Hills, Lee J., MD
Guidelines for Addressing Names of Firms:
When transcribing name of the firm, always copy as it is printed on the company’s letterhead, website or as mentioned in the directory. Under all circumstances, the abbreviations and punctations of the firm’s name are not to be changed.
For example:
Queens-Long Island Medical Group.
Beth-Israel General Hospital
Copper & Raunchy Pathology Lab.
Schwanam, Haslip and Kimbrell Dental Clinic
Guidelines for Addressing Persons with Business Titles:
While writing official letters or addressing people of higher business profile, mentioning the business title looks more professional and respectful. When a business title accompanies any name, it is usually written last after the degree or after the name separated by a comma but if the space does not permit it to be on the same line, it can be written on the next line without the use of the comma.
For example:
Levlin K. Mirchandani, MS, Medical Director
Kevin Kasparov, LLB
Chief of Sales
Benjamin F. Camille, MD, MS
Head of Forensic Sciences
Guidelines while writing address
The address is to be written immediately flushed to the next line after the name of the person or the firm.
Usually the address starts with street name, apartment or suite number, city, state and Zip code. One should not abbreviate North, South, West, Street, Avenue, Boulevard and even Apartment except when the address line is getting too big. Usually, it looks nice to have the whole address mentioned in two or three lines. The city name is always to be spelled out and separated with comma from the State. The state name can be abbreviated or can be spelled out and is separated from the zip code with one or two space but no comma or dash. There is no need to put comma or period at the end of the address line. Comma should only be used to separate the street and suite names or as in city and state name.
Finally, it is better to copy the address as mentioned on the letter head, website or as approved by the USPS.
For example:
Kathy Suekat, MD
One Nameoke Street, Suite QE
Far Rockaway, New York 11432
(One should always be spelled out when used in building, street, suite or apartment number)
Elaine Markowitz, MD
1465 Broadway,
Hewlett, New York 11551
Susan B. Johnson, LLB
Apartment 34,
1782 Collinmore Street
Luxemborg, MA 13456
Napil B. Pakisha, MD
PO Box 1934
Maples, CA 44560
Forms of Salutations:
After finishing with the address line starts the most important part of a letter i.e. salutation. This is a highly important protocol when starting the letter. Usually, it’s easier to write the salutation when a person addressed is single but becomes more difficult and more error prone, while addressing two or more people.
The salutation starts after leaving two blank lines after the address line and is to be followed by a colon or a comma as felt appropriate.
Here are some common ways of writing salutation:
Dear Paul: or Dear Paul,
Dear Dr. Ben: or Dear Doctor Ben:
Dear Drs. Mike and Lee or Dear Dr. Mike and Dr. Lee:
Dear Linda and Betty: or Dear Linda and Betty,
Dear Mrs. Kathy and Ms. Brenda:
Some examples for married couples.
Dear Mr. and Mrs. Bond:
Dear Professor Bill and Professor Kavita:
Dear Dr. Wu and Mrs. Cathy:
Dear Captain Pat and Professor Rina:
Dear Mr. Bright and Dr. Bright:
Some examples for unmarried couples associated with business or work purposes.
Dear Professor Paul and Mrs. Wright:
Dear Dr. Mills and Dr. Hilton:
Dear William and Nancy:
When addressing a large group together, use the standard salutation format.
Ladies and Gentleman:
Dear Professor McCarthy et al: (One can also use the name of the most senior person of the firm followed by et all, meaning all others.)
Guidelines to Use Attention Line:
Sometimes it becomes necessary to use the Attention line instead of going straight to salutation. When the attention line is used, it should be typed two blank spaces after the last address line flushed with the left margin. It should be written in full and usually capital form or even the first letter in caps would do but it is never to be abbreviated.
Example:
Attention: Mrs. Nancy P. Blake or ATTENTION: Mrs. Nancy P. Blake
If the title is going long, one can accommodate on the second line. For example:
Attention: Mrs. Nancy P. Blake
Purchasing officer
Always take care that the second line should start at the same point where the name of the person starts. This maintains clarity, visibility and neatness. It is wrong to use abbreviated form of Attention as Attn.
It is always debatable to use both the attention line and the salutation line. Some would like to use only the salutation format without any attention line while some would prefer to use the attention line. In any case, the salutation should always be in accordance with the attention line.
For example:
Attention: Mrs. Nancy P. Blake
Dear Madam,
This is the most frequent format used rather than using Dear Mrs. Nancy as mentioning the same name twice is improper.
So the start of a letter would look as follows:
May 28, 2006
Bethnovar Medical Clinic
1024 Nameoke Street, Suite 2B
Far Rockaway, New York 11621
Attention: Mrs. Nancy P. Blake
Dear Madam:
EPONYM USAGE
• Many terms in medicine, ranging from names of diseases to parts of the body to certain medical signs have been named after people. Eponymous terms are most commonly named after the person who first described them but occasionally they are named for famous patients who have had that condition.
For example:
Down syndrome
Ewing sarcoma
Arnold-Chiari malformation
Asperger syndrome
Gaucher disease
• Eponym is always capitalized but not the common nouns, adjectives, and prefixes that accompany them. Do not use possessive forms with eponyms.
For example:
Down syndrome (Correct)
Down's syndrome (Incorrect)
McBurney point (Correct)
McBurney's point (Incorrect)
non-Hodgkin lymphoma (Correct)
Gaucher disease (Correct)
• Adjectives and/or verbs derived from eponyms are not capitalized.
For example:
The patient is suffering from parkinsonism.
• Plurals of eponyms are made by adding s or es. Apostrophe is never used.
For example:
Babinskis (Correct)
Babinski's (Incorrect)
• The genus names should be capitalized only when in singular form and accompanied by a species name. Species name is never capitalized. The plurals and adjectival forms of genus are not capitalized.
For example:
Neisseria gonorrhoeae
Neisseria flavescens
Staphylococcus aureus
staphylococcal infection
meningococcal infection
staphylococci
For example:
Down syndrome
Ewing sarcoma
Arnold-Chiari malformation
Asperger syndrome
Gaucher disease
• Eponym is always capitalized but not the common nouns, adjectives, and prefixes that accompany them. Do not use possessive forms with eponyms.
For example:
Down syndrome (Correct)
Down's syndrome (Incorrect)
McBurney point (Correct)
McBurney's point (Incorrect)
non-Hodgkin lymphoma (Correct)
Gaucher disease (Correct)
• Adjectives and/or verbs derived from eponyms are not capitalized.
For example:
The patient is suffering from parkinsonism.
• Plurals of eponyms are made by adding s or es. Apostrophe is never used.
For example:
Babinskis (Correct)
Babinski's (Incorrect)
• The genus names should be capitalized only when in singular form and accompanied by a species name. Species name is never capitalized. The plurals and adjectival forms of genus are not capitalized.
For example:
Neisseria gonorrhoeae
Neisseria flavescens
Staphylococcus aureus
staphylococcal infection
meningococcal infection
staphylococci
Drug Terminology
In medical transcription , drug names have been classified in to generic names, trade names, and chemical names.
Generic name is also called the nonproprietary name. The generic name is the established and official name given to the drug. There is no restriction in the use of generic name. The WHO (World Health Organization) is the body, which coordinates the international nomenclature for the generic names, whereas USAN (US Adopted Names Council) establishes and approves official drug names in US.
As a rule, generic names are never capitalized. For example: aspirin, propranolol.
Sometimes, it might happen that the trade name and generic name of the drug are good sound-alikes. In such case, one should always use the generic spelling. For example: prednisone (generic), Prednisone (trade); KCl (generic), KayCiel (trade).
Brand names are also called as proprietary names: As understood, they are the names given by the manufacturer.
Brand names are always capitalized and always written as supplied by the manufacturer.
Therefore, some brand names such as RhoGAM, OxyContin, Peri-Colace, pHisoHex are written as published by the manufacturer.
Chemical name is rarely used in transcription and it describes the actual chemical structure of the drug.
Chemical names are never capitalized.
Dose and Dosages:
Dose represents quantity of drug to be administered at one time.
For example: Norvasc 500 mg.
Dosage represents the regimen of the drug, which is expressed in quantity per unit of time.
For example: Norvasc 500 mg b.i.d.
Latin abbreviations are to be used while expressing drug dosages. These are transcribed in the lower case with periods in between. Moreover, these should net be translated into English or vice versa. Also the most common mistake is to mix the Latin abbreviations due to improper dictation from the doctor.
For example: q.6 hours is wrong. It should be transcribed as q.4h. or every 4 hours.
Some commonly used Latin abbreviations are:
Abbreviation In Latin In English
a.e. ante cebum before meals
b.i.d. bis in die twice a day
h. hora hour
h.s hora somni at bedtime
n.p.o. nil per os nothing by mouth
n.r. non repetatur do not repeat
o.d. onmi die everyday
p.c. post cebum after meals
p.p. postprandial following a meal
p.o. per os by mouth
p.r.n. pro re nata as needed
q. quaquae every
q.a.m. ququae ante every morning
Do’s and don’ts:
Drug names, their dosages, and instructions are never separated by commas.
For example: The patient is to take Norvasc 500 mg p.o. b.i.d. for pain .
Drugs in series: In case of a series of drugs along with their dosages and instructions, use the comma to separate the drug entities, but do not place commas between drugs and their dosages.
For example: The patient is discharged home on Zantac 150 mg b.i.d., Lasix 20 mg p.o. t.i.d., and Tenormin 50 mg b.i.d.
If drugs in the series are separated by commas, i.e. they have internal commas, semicolon is used to separate the drug entities.
For example: The patient will be on Humulin insulin 70/30, 15 units before breakfast and 15 units before dinner; Lasix 20 mg p.o. t.i.d.; and Cipro 500 mg p.o. b.i.d.
Transcribing Vitamins: Vitamin is used in the lower case unless sentence starts with it, which is then followed by space and followed by capital alphabet, and Arabic numeral if present. There should be no space between Arabic numeral and alphabet.
For example: vitamin B, vitamin B12, vitamin B6, vitamin A.
Radioactive drugs are referred to by use of isotopes. While transcribing them never place a hyphen between element and isotope number.
The isotope number is placed following the name of the element after one space on the same line. For example: technetium 99m.
If an abbreviated form of an element is dictated, then the isotope number precedes the symbol for the element on the same line without any space.
For example: 99mT technetium 99m.
If sentence starts with the isotope, it is customary to spell it out.
For example: Technetium 99m was utilized for the scan.
Follow the style of manufacturer in case of brand names of isotopes.
Generic name is also called the nonproprietary name. The generic name is the established and official name given to the drug. There is no restriction in the use of generic name. The WHO (World Health Organization) is the body, which coordinates the international nomenclature for the generic names, whereas USAN (US Adopted Names Council) establishes and approves official drug names in US.
As a rule, generic names are never capitalized. For example: aspirin, propranolol.
Sometimes, it might happen that the trade name and generic name of the drug are good sound-alikes. In such case, one should always use the generic spelling. For example: prednisone (generic), Prednisone (trade); KCl (generic), KayCiel (trade).
Brand names are also called as proprietary names: As understood, they are the names given by the manufacturer.
Brand names are always capitalized and always written as supplied by the manufacturer.
Therefore, some brand names such as RhoGAM, OxyContin, Peri-Colace, pHisoHex are written as published by the manufacturer.
Chemical name is rarely used in transcription and it describes the actual chemical structure of the drug.
Chemical names are never capitalized.
Dose and Dosages:
Dose represents quantity of drug to be administered at one time.
For example: Norvasc 500 mg.
Dosage represents the regimen of the drug, which is expressed in quantity per unit of time.
For example: Norvasc 500 mg b.i.d.
Latin abbreviations are to be used while expressing drug dosages. These are transcribed in the lower case with periods in between. Moreover, these should net be translated into English or vice versa. Also the most common mistake is to mix the Latin abbreviations due to improper dictation from the doctor.
For example: q.6 hours is wrong. It should be transcribed as q.4h. or every 4 hours.
Some commonly used Latin abbreviations are:
Abbreviation In Latin In English
a.e. ante cebum before meals
b.i.d. bis in die twice a day
h. hora hour
h.s hora somni at bedtime
n.p.o. nil per os nothing by mouth
n.r. non repetatur do not repeat
o.d. onmi die everyday
p.c. post cebum after meals
p.p. postprandial following a meal
p.o. per os by mouth
p.r.n. pro re nata as needed
q. quaquae every
q.a.m. ququae ante every morning
Do’s and don’ts:
Drug names, their dosages, and instructions are never separated by commas.
For example: The patient is to take Norvasc 500 mg p.o. b.i.d. for pain .
Drugs in series: In case of a series of drugs along with their dosages and instructions, use the comma to separate the drug entities, but do not place commas between drugs and their dosages.
For example: The patient is discharged home on Zantac 150 mg b.i.d., Lasix 20 mg p.o. t.i.d., and Tenormin 50 mg b.i.d.
If drugs in the series are separated by commas, i.e. they have internal commas, semicolon is used to separate the drug entities.
For example: The patient will be on Humulin insulin 70/30, 15 units before breakfast and 15 units before dinner; Lasix 20 mg p.o. t.i.d.; and Cipro 500 mg p.o. b.i.d.
Transcribing Vitamins: Vitamin is used in the lower case unless sentence starts with it, which is then followed by space and followed by capital alphabet, and Arabic numeral if present. There should be no space between Arabic numeral and alphabet.
For example: vitamin B, vitamin B12, vitamin B6, vitamin A.
Radioactive drugs are referred to by use of isotopes. While transcribing them never place a hyphen between element and isotope number.
The isotope number is placed following the name of the element after one space on the same line. For example: technetium 99m.
If an abbreviated form of an element is dictated, then the isotope number precedes the symbol for the element on the same line without any space.
For example: 99mT technetium 99m.
If sentence starts with the isotope, it is customary to spell it out.
For example: Technetium 99m was utilized for the scan.
Follow the style of manufacturer in case of brand names of isotopes.
Diabetes Mellitus Terms
The American Diabetes Association (ADA) has categorized diabetes mellitus into the following types:
Type 1, insulin-dependent diabetes, which requires insulin usage for life time.
Type 2, non-insulin-dependent diabetes, which does not require insulin for sustaining life. Change in lifestyle, eating habits, exercise, oral hypoglycemics may be used to keep it under control.
Impaired glucose tolerance, in which glucose levels are between normal and diabetic.
Gestational diabetes, develops in women during pregnancy and usually resolves after pregnancy.
Proper way of transcription – "Type" is followed by Arabic letter "1 or 2" in whic type is lower cased unless starting the sentence. Hyphen is not used to join the "type" with "Arabic numeral."
For example: Type 1 diabetes mellitus or diabetes mellitus type 2.
Non-insulin-dependent and insulin-dependent are always hyphenated either preceding or following the noun "diabetes."
Insulin Terminology:
There are namely four types of insulin classified as:
Fast acting (Humalog insulin)
Short acting (Regular insulin)
Intermediate acting (NPH and Lente)
Extended or long acting: (ultralente insulin)
How to write the concentration:
Concentration of insulin is measured in units per milliliter of blood. Normally, the insulin is transcribed as 40 units, 35 units and so on but the ideal way is to write a capital letter "U" followed by number of milliliters without any space between U and numeral to describe its concentration.
For example:
U35: 35 units of insulin per milliliter of blood.
U 70: 70 units of insulin per milliliter of blood.
Caution: The old theory of transcribing Ad verbatim should always be applied and transcribe as dictated. If U is dictated, transcribe U. If units is dictated, transcribe units and there is no need to change it to U.
Type 1, insulin-dependent diabetes, which requires insulin usage for life time.
Type 2, non-insulin-dependent diabetes, which does not require insulin for sustaining life. Change in lifestyle, eating habits, exercise, oral hypoglycemics may be used to keep it under control.
Impaired glucose tolerance, in which glucose levels are between normal and diabetic.
Gestational diabetes, develops in women during pregnancy and usually resolves after pregnancy.
Proper way of transcription – "Type" is followed by Arabic letter "1 or 2" in whic type is lower cased unless starting the sentence. Hyphen is not used to join the "type" with "Arabic numeral."
For example: Type 1 diabetes mellitus or diabetes mellitus type 2.
Non-insulin-dependent and insulin-dependent are always hyphenated either preceding or following the noun "diabetes."
Insulin Terminology:
There are namely four types of insulin classified as:
Fast acting (Humalog insulin)
Short acting (Regular insulin)
Intermediate acting (NPH and Lente)
Extended or long acting: (ultralente insulin)
How to write the concentration:
Concentration of insulin is measured in units per milliliter of blood. Normally, the insulin is transcribed as 40 units, 35 units and so on but the ideal way is to write a capital letter "U" followed by number of milliliters without any space between U and numeral to describe its concentration.
For example:
U35: 35 units of insulin per milliliter of blood.
U 70: 70 units of insulin per milliliter of blood.
Caution: The old theory of transcribing Ad verbatim should always be applied and transcribe as dictated. If U is dictated, transcribe U. If units is dictated, transcribe units and there is no need to change it to U.
Decimal Usage
• While transcribing decimals, periods are to be used “.”
• While transcribing quantities less than 1, zero (0) is placed before the decimal followed by the numeral value.
For example:
Clonidine.25 mg (Incorrect):
Clonidine 0.3 mg (Correct):
• While transcribing metric measurements, like cm, mg, mm, if fractions are dictated,
they should be converted to decimals and transcribed.
For example:
(Dictated): The cyst was two and a half cm in size.
(Transcribed): The cyst was 1.5 cm in size.
• But when only whole numbers are dictated and fractions are not dictated, then decimal point and zero should not be placed though it does not changes the value.
For example:
(Correct): The patient was given dexamethasone 5 mg IV.
(Incorrect): The patient was given dexamethasone 5.0 mg IV.
But there is an exception to this as mentioned below.
• However, laboratory values and pathology specimens should be transcribed as
dictated, even if decimal point and zero are dictated following the whole number.
Similarly, if they are not dictated, one should not place them on their own.
(Dictated): The cyst measured 2.2 x 3.0 x 2.3 cm.
(Transcribed): The cyst measured 2.2 x 3.0 x 2.2 cm. (Correct)
The cyst measured 2.5 x 3 x 2.8 cm. (Incorrect)
Now take the second example.
(Dictated): The cyst measured 2 x 4 x 1.5 cm.
(Transcribed): The lesion measured 2 x 4 x 1.5 cm. (Correct)
The lesion measured 2.0 x 3.0 x 1.6 cm. (Incorrect)
• While transcribing quantities less than 1, zero (0) is placed before the decimal followed by the numeral value.
For example:
Clonidine.25 mg (Incorrect):
Clonidine 0.3 mg (Correct):
• While transcribing metric measurements, like cm, mg, mm, if fractions are dictated,
they should be converted to decimals and transcribed.
For example:
(Dictated): The cyst was two and a half cm in size.
(Transcribed): The cyst was 1.5 cm in size.
• But when only whole numbers are dictated and fractions are not dictated, then decimal point and zero should not be placed though it does not changes the value.
For example:
(Correct): The patient was given dexamethasone 5 mg IV.
(Incorrect): The patient was given dexamethasone 5.0 mg IV.
But there is an exception to this as mentioned below.
• However, laboratory values and pathology specimens should be transcribed as
dictated, even if decimal point and zero are dictated following the whole number.
Similarly, if they are not dictated, one should not place them on their own.
(Dictated): The cyst measured 2.2 x 3.0 x 2.3 cm.
(Transcribed): The cyst measured 2.2 x 3.0 x 2.2 cm. (Correct)
The cyst measured 2.5 x 3 x 2.8 cm. (Incorrect)
Now take the second example.
(Dictated): The cyst measured 2 x 4 x 1.5 cm.
(Transcribed): The lesion measured 2 x 4 x 1.5 cm. (Correct)
The lesion measured 2.0 x 3.0 x 1.6 cm. (Incorrect)
CAPITALIZATION GUIDELINES
Capitalization has always been a nagging question especially for the early beginners of transcription. Here we discuss some basic rules of capitalization that are to be kept in mind when transcribing medical reports:
Capitalize all the proper nouns-This includes names of a person, place, organization, languages, countries, races, days of the week, and months.
For example:
George Bush
English
France
White House
Monday
June
Capitalize brand names of drugs and not their generic names.
For example:
aspirin (generic) should be small unless the sentence starts with it.
Ecotrin (brand name)
As discussed earlier, capitalize the words building, center, room, only when they accompany a proper noun or are part of the official name, otherwise not.
For example:
Washington State Building
The patient was taken to Mercy Medical Center.
Capitalize eponyms, but do not capitalize the adjectives, prefixes, and common nouns that accompany them. Also, do not capitalize the nouns, adjectives, and verbs derived from eponyms.
For example:
non-Hodgkin’s lymphoma
Parkinson’s disease
red rubber Robinson catheter
parkinsonism
pasteurized milk
All Acronyms are transcribed in upper-case letters (capitalized) except for a few, like wbc, rbc.
For example:
CABG from coronary artery bypass grafting.
COPD from chronic obstructive pulmonary disease
However, in abbreviated form (like S aureus, H pylori), the genus is capitalized.
Capitalize compass directions (east, west, north, south) when part of the geographic name, otherwise not.
For example:
East Africa
South Korea
His house is in the west where the dark men reign.
Capitalize name of religious holidays and festivals.
For example:
Thanksgiving
Memorial Day
Christmas Day
New Year Day
Always capitalize sociocultural designations like races, religions.
For example:
Spanish
African-American
Hispanic
Caucasian
Methodist
Capitalize all the proper nouns-This includes names of a person, place, organization, languages, countries, races, days of the week, and months.
For example:
George Bush
English
France
White House
Monday
June
Capitalize brand names of drugs and not their generic names.
For example:
aspirin (generic) should be small unless the sentence starts with it.
Ecotrin (brand name)
As discussed earlier, capitalize the words building, center, room, only when they accompany a proper noun or are part of the official name, otherwise not.
For example:
Washington State Building
The patient was taken to Mercy Medical Center.
Capitalize eponyms, but do not capitalize the adjectives, prefixes, and common nouns that accompany them. Also, do not capitalize the nouns, adjectives, and verbs derived from eponyms.
For example:
non-Hodgkin’s lymphoma
Parkinson’s disease
red rubber Robinson catheter
parkinsonism
pasteurized milk
All Acronyms are transcribed in upper-case letters (capitalized) except for a few, like wbc, rbc.
For example:
CABG from coronary artery bypass grafting.
COPD from chronic obstructive pulmonary disease
However, in abbreviated form (like S aureus, H pylori), the genus is capitalized.
Capitalize compass directions (east, west, north, south) when part of the geographic name, otherwise not.
For example:
East Africa
South Korea
His house is in the west where the dark men reign.
Capitalize name of religious holidays and festivals.
For example:
Thanksgiving
Memorial Day
Christmas Day
New Year Day
Always capitalize sociocultural designations like races, religions.
For example:
Spanish
African-American
Hispanic
Caucasian
Methodist
Subscribe to:
Posts (Atom)