MT Training > Transcription rules

VII. Cancer Classifications 

• Stage and grade - do not capitalize either one if it does not begin a sentence. 
• Use Roman numerals for cancer stages. 
• Use Arabic numerals for cancer grades. 
• For clarity, use capital letters or arabic suffixes without spaces or hyphens.

Here are some examples: 

VIII. Drug Terminology

• If dictated q.day - transcribe q.d. 
• If dictated q. four hours - transcribed as q.4h. not q. 4 hours. 
• When referring to drugs including strength, dosage and directions - Use Arabic numerals only.  Example - The patient was prescribed penicillin 500 mg t.i.d. for 5 days. 
• If there is no whole number, always add a 0 in front of the decimal point for clarity - this is a general rule when transcribing numbers, not just medications.  Example - Dictated as Synthroid point 75 mg a day.  Transcribe as Synthroid 0.75 mg q.d. 
• Be aware that some drugs are commonly dictated in either milligrams or micrograms. Example -  Synthroid 0.05 mg or Synthroid 50 mcg. 

IX. Lab Test Punctuation Guidelines

• Use commas to separate multiple related test results. Here are some examples: 
  • Creatinine 1.2, BUN 42, phosphorus 4.3. 
  • WBC 12.4 with 72 segs, 9 lymphs. 
  • CBC reveals an RBC count of 10.2, WBC 6.8, platelets 220,000, reticulocyte count 1 with 3 monos, 1 eos and 0 basos. 
  • Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100 and glucose of 80. 
• Use periods to separate unrelated laboratory test results. For example, 
  • Potassium 3.7. TSH 1.0. Albumin 4.0. 

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