Transcription rules

Names

Names with junior or senior attached. Use a comma before and a period after the abbreviation or use neither.
- Example - Jeramiah Johnson, Jr. or Jeramiah Johnson Jr
- Incorrect - Jeramiah Johnson Jr.
Names with ordinals. Do not use comma between name and ordinal.
- Example - Bernie Schwartz III
- Incorrect - Bernie Schwartz, III

XI. Report Section Notes

History of Present Illness - Mainly in present tense, but mixed tense may be appropriate.

Past Medical History - Use past tense.

Allergies

Allergies are typed either ALL CAPITAL LETTERS or bold font depending on client preference. Example - If the allergy is dictated pcn, type PENICILLIN.
If the patient has no allergies use the phrase, "No known drug allergies."

Medications

Transcribe in continuous paragraph format, even when the doctor numbers the medications. Example: Penicillin 500 mg t.i.d. for 5 days, levothyroxine 0.75 mg q.d. and Lopressor 50 mg b.i.d.
Capitalize brand name medications. DO NOT capitalize generic medications.
Use Latin drug abbreviations. Example - if dictated every day - transcribe q.d. If dictated every four hours - transcribe q.4h. not q. 4 h.
Don't mix Latin and English terminology. Example: If dictated q. day - transcribe q.d. NOT q. day.
When referring to strength, dosage and directions - Use Arabic numerals only.
If there is no whole number, add a zero 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 milligrams a day. Transcribe Synthroid 0.75 mg q.d.

Physical Examination

Transcribe in present tense in ALL of the major report formats.
Vital Signs - Should look like this: Temperature 98.0, BP 140/80, pulse 76 and regular, respirations 16.

Assessment/Diagnosis/Impression

Typed entirely in upper case.
No abbreviated medical terminology. Type the entire term or phrase. Example - If the doctor dictates CAD, type coronary artery disease.
Numbers follow the same rules for any section of the transcript. Example - A 31-YEAR-OLD FEMALE. 5 MG.
Abbreviate units of measure, e.g. MG, MM, CM, etc.
The title Doctor is written out, not abbreviated.

Verb tenses

Use past tense:
- In the past history of a report
- In discharge summaries EXCEPT for the History of Present Illness and the Physical Examination sections.
- When discussing expired patients

Use present tense:
- To describe the physical examination
- Use the correct verb tense to communicate the appropriate time of the action. Even if the dictator inadvertently changes tense during the dictation.

XII. Things to check when proofreading a document