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.
