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TRANSCRIPTION GUIDELINES

RULES IMPLEMENTED BY AAMT - American Association of Medical Transcriptionist JCAHO - Joint Commission on Accreditation of Healthcare Organization.

RULES REGARDING DATE 1.Header : mm/dd/yy format

2.Body

Month date with year (June 16, 2010) If only month and year- no comma is used (June 2010)

RULES REGARDING PATIENTS NAME 1.Header : 2.Body : Last name, first name First name last name

RULES REGARDING DOCTORS NAME


1. Do not use MD, if designation Dr. is given in front and vice versa. Eg. Dr. John Smith or John Smith, MD. 2. Put 1 space after Dr. before the name. 3. In letter put colon with doctors name. Eg. Dear Dr. John: RULES OF CAPITALIZATION 1. All proper names are capitalized. 2. All brand/ trade names of the drug are capitalized. 3. Start a sentence with capital letter. 4. All races except white and black are capitalized. 5. All postal code/ country code are written in capital letters. 6. pH 7. Rh 8. Chemical elements.

RULES OF PERIOD ( FULL STOP)

1. After every sentence. 2. When listing out items- in medications, allergies, diagnoses, etc. 3. Used with designation- Mr., Mrs., Dr., Jr., Sr. 4. Used with Latin abbreviation- a.m., p.m., p.r.n., b.i.d., p.o.

RULES OF COLON

1. After all headings in header and footer- Main or subheadings. 2. Used in ratios Eg. 2:3 3. Used with time Eg. 5:30 a.m. 4. Used while saluting doctors in letters.

RULES OF VIRGULE (SLASH)

1. Used in place of over/ by/out of/ per

2. In visual acuity : 20/20


NB: Do not use more than 1 virgule in a unit. Eg. 4ml/kg/min --- is wrong 4ml/kg per minis correct

RULES OF APOSTROPHE

1. Do not use apostrophe with capital abbreviation, but needed with plural of lower cased abbreviation. Eg. WBCs, RBCs wbcs, rbcs
2. Used with single numerals but not with numerals more than 2 digits. Eg 4s, 6s, 200s, 1950s. 3. With possession.

RULES OF NUMBERS

1. Do not use comma when there are only 4 digits. Eg 1234 2. Put comma after every three digits (starting from back) if there are more than five digits. Eg 123,456 234,567,890 3. If the number has a decimal point do not use comma regardless of the number of digits. Eg 56467857821.2 4. For phone numbers

Eg 1234-2356
0478324-6734

5. For zip code


Eg CA 12563-4670 (CA is the country code for California). 6. All numbers between 0 9 are written in words and numbers above 9 are written as numerals.

RULES OF HYPHEN (do not put space before and after hyphen)
1. Use hyphen in a noun to noun compound modifier. Eg father-son relationship, doctor-patient conversation 2. Use hyphen when two or more words are used as a single modifier before a noun. Eg This is a well-developed patient. The patient is well developed.

3. Use hyphen with preposition to . Eg left-to-right top-to-bottom end-to-end anastomosas 4. Used in place of to and through. Eg The pain is 8 in a 0-10 scale. Cranial nerves II-XII are intact.
5. Used with single letters joined to a word. Eg T-shirt, X-ray.

6. Used to express sutures. Eg 2-O nylon, 4-O vikryl 7. Use hyphen to express space between 2 vertebrae (but not between different vertebrae). Eg C1-C7.

8. Used with fractions.


Eg 1/2-teaspoon,3/4-inch 9. With chemical elements. Eg I-131, U-235

Other examples Mother-in-law over-the-counter figure-of-eight 26-year-old man 26-month-old baby 26-day-old infant low-grade-fever moderate-to-severe