Account Specifics
Note: Copying and pasting is not permitted in any part of the course, including reports.
Scrubbed information
For confidentiality reasons, you will hear gaps in the audio where personal identifiers have been
removed. When this is encountered please insert [Name], [Place], or [Date] where applicable. For
more on dates, please refer to the appropriate section below.
Verbatim
This is a verbatim account with the exception of grammatical errors. You should not add in text that is
not dictated. Often you will hear sentence fragments rather than complete sentences, and these
should be typed as dictated. Note: In the course both “patient” and “the patient” are acceptable.
You must correct subject/verb agreement.
Example:
Dictated: The abdomen are soft and nontender.
Transcribed: The abdomen is soft and nontender.
Dictated: The lungs is clear.
Transcribed: The lungs are clear.
You must correct verb tense.
Example:
Dictated: The abdomen is soft. There was a 2 cm midline scar.
Transcribed: The abdomen is soft. There is a 2 cm midline scar.
If a dictator says a redundant word/phrase or corrects himself that should be changed or corrected. If
you are not certain, leave a blank.
If a dictator gives an incorrect drug dosage or uses an incorrect medical word, this must be flagged to
QA. Often time dictators will spell a medical word or drug for the transcriptionist. Please do not
assume the spelling is correct. You must research to verify the correct spelling.
Formatting
Sentence fragments are okay. All text should be left aligned. Do not indent or use tabs.
Spacing after a period or colon can be either 1 space or 2, as long as it is consistent. Spacing after a
semicolon, comma, etc. must be 1 space.
Paragraphs: New paragraphs should be formed for each major sections of the report. Ex: Review
of systems, physical examination, allergies, social history, family history, medications, laboratory
data, imaging studies, etc. should all be in separate paragraphs. Errors will be given if new
paragraphs are not created for these sections.
Within each specific section, paragraphs should be created for change of topic/thought. Some
paragraphs can become very long and difficult to read if not separated. If paragraphs are not formed
where the key has one inserted, errors will not be given. As you become more familiar with
transcription of medical reports, knowing where to put a new paragraph will become easier. If you are
making a new paragraph, please use 2 returns, so a blank line is inserted between paragraphs.
Headings: Major headings will be type in all capitals. No colon will be used after the heading. Text
will begin on the line immediately below the headings.
Do not add headings or subheadings if not dictated. For exceptions, please refer to the
Diagnoses/Impression/Assessment section below.
NOTE: Abbreviations and brief forms such as preop, postop, and exam should be transcribed as
dictated in headings.
Sometimes a dictator may say a heading at the beginning of a dictation, such as "operative report" or
"procedure note" and so on. You may see this at the top of some of the dictation keys. You do not
need to type this in your reports; however, if you do type it, it will not be marked as an error. When
you get to the point where you have to select specific templates for different work types, this is the
way of the dictator helping you decide what template to use.
The physical examination will be transcribed as dictated. If dictated in paragraph form, transcribe it
that way. If dictated with subheadings, stack as seen in the example below. All subheadings will be
in mixed case format with the exception of HEENT/ENT, which is always typed in all capitals.
Note: You may see 2-word subheadings written with only an initial cap, such as Vital signs or
General appearance. If you write these with initial caps on both words, these will not be marked as
errors, although they will be highlighted as differences.
Example - dictated with subheadings, transcribed in list format:
PHYSICAL EXAMINATION
The patient was alert and oriented and in no acute distress.
Vital Signs: BP 150/72, P 72, RR 12.
HEENT: Throat clear. Tympanic membranes pink.
Heart: Regular rate and rhythm.
Lungs: Clear.
Abdomen: Not examined.
Neurologic: Cranial nerves 2-12 intact.
Example – If dictated in sentence format, transcribe in paragraph form:
On physical examination, the patient was alert and oriented and in no acute distress. Vitals showed
BP 150/72, P 72, RR 12. HEENT exam showed tympanic membranes to be pink. Heart had a
regular rate and rhythm. The lungs were clear. The abdomen was not examined. On neurologic
exam the cranial nerves 2-12 were intact.
If there is a combination of complete sentences for some components and subheadings for other
components, transcribe stacked and do not create subheadings that have not been dictated.
Example – If dictated in mixed format, subheadings, and sentences; transcribe in list format:
PHYSICAL EXAMINATION
The patient was alert and oriented and in no acute distress.
Vital Signs: BP 150/72, P 72, RR 12.
HEENT: Throat clear. Tympanic membranes pink.
The heart has a regular rate and rhythm.
The lungs are clear.
The abdomen is not examined.
Neurologic: Cranial nerves 2-12 intact.
Allergies
POSITIVE ALLERGIES WILL BE IN CAPS. Negative allergies will be in mixed case.
Example:
ALLERGIES
No known drug allergies.
ALLERGIES
PENICILLIN, CODEINE, and SYNTHROID. (NOTE: "and" is not capitalized.)
ALLERGIES
He is allergic to SHELLFISH. (NOTE: The allergen is in capitals, but the rest must be in lower case.)
Diagnosis(es)/Impression/Assessment
If there is only 1 diagnosis/impression/assessment, do not number, even if the dictator says "number
1." If there is more than 1 diagnosis/ impression/assessment, always number each one and put them
in a numbered list format, even if they are not dictated that way.
These sections will be transcribed as headings, regardless if they are dictated as a sentence or not.
Example:
Dictated: The impressions are bronchitis, and asthma exacerbation.
Transcribe:
IMPRESSION
1. Bronchitis.
2. Asthma exacerbation.
CLINICAL DIAGNOSIS
Coronary artery disease.
DIAGNOSES
1. Obstructive sleep apnea.
2. Coronary artery disease.
3. Hypertension.
In an operative report, the dictator may dictate “same” for the postoperative diagnosis. When this
happens, you must transcribe the same text as you did for the preoperative diagnosis. Do not type
“same” or this will be counted as a protocol failure error.
Blanks/Discrepancies
Everyone at some point has a word that they cannot understand or a medication that they cannot
find. However, the goal is to leave as few blanks as possible in any given report. After due diligence,
in terms of searching samples and using resources such as Quick Look Drug Book or Stedman’s, the
appropriate way to leave a blank in a report is 5 underscores, _____. You may also mark a guess in
the document in parentheses.
Example:
The patient was _____ (cachectic) on exam.
A discrepancy is conflicting information.
Example:
Dictated: She has pain in her right leg, and we put a cast on her right arm.
Transcribe: She has pain in her right_____ (leg), and we put a cast on her right _____ (arm).
This flags the report in both places, and someone in a QA position would audit it for accuracy.
Numbering
Do not begin a sentence with a number. This should be changed to a word. However, if the number
represents a dosage or lab value, the sentence will need to be recast.
All numbers will be typed in Arabic format, even those below 10. Here are a couple of exceptions to
this rule. For others, refer to Book of Style Section 3, Chapter 10. This chapter also talks about the
use of roman numerals.
The patient has stage IV cervical cancer. (Use roman numerals as per BOS 10.1.2).
Spell out the number "one" when used as a noun or pronoun.
With the exception of diagnoses, do not create a numbered list if not dictated this way.
Example:
She will be the one to contact us to schedule an appointment.
The physician compared his right arm with the other one.
When zero is used as a general expression, spell it out. If used as a unit of measure or classification,
use the numeral.
Example:
She had zero tolerance for nonsense in the classroom.
He assessed that his pain was 0 on a scale of 0-5.
Ordinal numbers are used to indicate order or position in a series rather than quantity. In the health
record, however, all ordinals should be expressed with numerals (1st, 2nd, etc.) to promote clarity of
communication. Do not use a period with ordinal numbers.
Example:
She saw the nurse practitioner in her 2nd trimester.
He should come back to the office on the 5th day after his surgery.
Date
Transcribe dates verbatim. However, do not use ordinal numbers. If the date has been completely
scrubbed from the document, type this as [Date]. Exception: The patient was seen on the 7th.
Example:
Dictated: April 1st, 2012
Transcribed: April 1, 2012
Dictated: April 1st
Transcribed: April 1
Dictated: 6th June
Transcribed: 6 June
Dictated: 6th of June
Transcribed: 6 June
Dictated: April of 2012
Transcribed: April 2012
Dictated: "four….ten….ninety-eight"
Transcribed: 4/10/98
Dictated: April of this year.
Transcribed: April of this year
Dictated: May of "blank."
Transcribed: May of [Year] or May (This may show up as a difference on your compare document,
but will not be counted as an error.)
Dictated: The patient was seen in the office on "blank."
Transcribed: The patient was seen in the office on [Date].
Dictated: May of 07
Transcribed: May of 07
Dictated: May 09
Transcribed: May ‘09
Capitalization
Departments/clinics: Capitalize the name of any department/clinic that follows the name of the
facility it belongs to. Otherwise, it is “generic” and could belong to any facility, and would not be
capitalized. Refer to Book of Style 7.3.4 for more information.
Example:
The patient presented to the Toronto General Emergency Department last night.
The patient presented to the emergency department last night.
Specialties: Book of Style states that when a specialty is used as an organizational entity, it will be
capitalized. When it is their primary or common meaning that is being referred to in the sentence,
they should not be capitalized.
Example:
The specimen was sent for pathology. (Meaning the service).
The specimen was sent to Pathology. (Meaning the departmental entity).
The patient will be seeing Derm. (Meaning the departmental entity).
The patient will be seeing the derm department. (Generic. Not associated with a specific hospital).
Capitalize all eponyms (words named after a person), proper nouns, personal names, and places
(countries, cites, streets, continents, body of water, etc.). Read more about eponyms below.
Drugs: Capitalize brand name drugs appropriately. You can refer to the Quick Look Drug Book
located in your E-books to help you distinguish between a brand and generic drug name. Read more
under the medication section below.
Abbreviations
Abbreviations that represent diseases should be transcribed as dictated, except in diagnosis,
assessment, impression sections where they must be expanded. However, nondisease-entity
abbreviations such as units of measure and laboratory tests do not need to be expanded. See Book
of Style 9.1.7 for more details. Note – Brief forms are not considered abbreviations in the course.
Example:
Dictated: Diagnosis CHF.
Transcribed:
DIAGNOSIS
Congestive heart failure.
Dictated: Diagnosis lung CA on CT scan.
Transcribed:
DIAGNOSIS
Lung cancer on CT scan.
Dangerous abbreviations, as per the Book of Style, should not be used. Please refer to the Book of
Style 9.3.1 for a list of dangerous abbreviations that should be avoided.
Example:
Dictated: Blood loss 300 cc.
Transcribed: Blood loss 300 mL.
Eponyms
An eponym is a word that is named after a person. The eponym will be typed with an initial capital.
However, do not capitalize the noun following it.
Example:
Lyme disease (not Lyme Disease)
Foley catheter (not Foley Catheter)
If an eponym is written in the verb or adjective form, we do not capitalize it.
Example:
bovied (from Bovie cautery)
parkinsonism (from Parkinson disease)
When an eponym is followed by a noun, the “apostrophe s” is dropped. If the eponym is not followed
by a noun, an “apostrophe s” is added.
Example:
The patient has Alzheimer disease.
The patient has Alzheimer’s.
Medications
Medications will be typed verbatim. Do not list if not dictated as a list.
Brand name drugs are capitalized, generic drugs are not capitalized. Names of illegal/illicit drugs are
not capitalized.
Example:
Ativan (brand name)
lorazepam (generic name)
heroin (illegal)
cocaine (illegal)
Refer to the Quick Look Drug Book found in your E-books to distinguish between brand and generic
drug names.
Trailing 0’s: Do not transcribe a trailing 0 in a drug dosage, even if dictated. The decimal may be
missed, and this could result in the patient getting a drug dose of 10 times the prescribed limit.
Example:
Dictated: Ativan 2.0 mg
Transcribed: Ativan 2 mg
Leading 0’s: You must transcribe a leading 0 in a drug dosage of less than 1, even if not dictated.
The decimal may be missed and this could result in the patient getting a drug dose of 10 times the
prescribed limit.
Example:
Dictated: The patient was prescribed .4 mg of Flomax.
Transcribed: The patient was prescribed 0.4 mg of Flomax.
NOTE: If a trailing 0 is dictated in a lab value, you should transcribe this. If a leading 0 is dictated,
this must also be transcribed.
Example:
White blood count 5.2, hemoglobin 14.0, hematocrit 37.
The patient had a 0.8 cm lesion on the upper lip.
Miscellaneous
Contractions: Contractions are not used in medical transcription, except in a direct quote.
See Book of Style 9.1.12.
Example:
Dictated: It’s time to give him his medication.
Transcribed: It is time to give him his medication.
Dictated: The woman yelled, “It’s on fire.”
Transcribe: The woman yelled, “It’s on fire.” (Direct quote)
Times (x):
If transcribing an x to replace the word times (referring to how many times something was done) it is
to be used only with digits. Do not space between the x and the digit.
Example
Dictated: The patient has been admitted times three.
Transcribed: The patient has been admitted x3.
Cut off Dictation: Sometimes dictators do not complete their dictations. This can be for a variety of
reasons, such as disconnecting too soon or system errors. When you come across a report that is
not complete, type CUT OFF at the point the audio ends.
Insert a "normal" or "template:" You may hear this in some of your reports. If the dictator says to
insert a normal, a template, or his "standard dictation" in the report, you may type his directions into
your document. This may look different than the key, but will not be marked as an error.
Proofreading: Please remember to carefully proofread your document before you submit your
reports.
References:
Please be sure that your references are reputable medical references, such as the Book of Style or
your Stedman's resources.
When verifying information you must follow the below hierarchy.
1. Your first reference will be the account specifics.
2. Your second reference will be the Book of Style, when you can’t find the information in the
account specifics.
3. Your third reference will be the school-issued Stedman’s resources if you can’t find it in the
primary or secondary resources.
4. Your fourth reference will be other Internet sources, making sure to establish integrity and
authority of specific sites.
NOTE: If you cannot find a rule above that addresses your question on transcription, refer to the
Book of Style.
Corrections: Dictators will often add or delete dictated information in a report. It is important that
you recognize when the dictator has made a change and correct the dictation as directed. It can
mean adding or deleting sentences depending on the correction. An effort must be made by the
student to correct the dictation. If the dictation is not corrected, as indicated by the dictator, or both
the undesired text and the correction are included in the document, error points will be deducted.
Note: Copying and pasting is not permitted in any part of the course, including reports.