STYLE GUIDE - J.b5z

STYLE GUIDETranscription is a reflection of the healthcare provided.

TABLE OF CONTENTSABBREVIATIONS. 3APOSTROPHES . 6CAPITALIZATION . 7COLONS . 9COMMAS . 9COMMONLY CONFUSED TERMS . 11DATES/TIMES . 13DIAGNOSES . 14DIAGNOSTIC DATA . 17HYPHENS . 18NUMBERS . 18PLURALS . 22QUOTATION MARKS . 22COMMAS . 22REPORT FORMAT RULES . 23SYMBOLS . 26In addition to information contained in the Style Guide please refer to the following for furtherexplanations and help:QA Team Bulletin boardSTS websiteMT resources listed on STS website2 of 2808/06/12

ABBREVIATIONSAbbreviations, acronyms, and brief forms are often used in medical dictation to speed upcommunication, but they frequently create confusion instead. In the numerous publicationsdevoted to translating medical abbreviations, abbreviations with a single meaning appear to bein the minority. Clarity of communication is essential. Avoid the use of abbreviations, acronyms,and brief forms except for internationally recognized and accepted units of measure for widelyrecognized terms and symbols. Do not use any that readers will not immediately recognize.There is no nationally recognized list of approved abbreviations for use in medical reports, nordoes AHDI propose such a list. However, it is important to note that the Joint Commission onAccreditation of Healthcare Organizations (JCAHO) requires that in order to be accredited ahospital should use uniform data definitions whenever possible; they note that an abbreviationlist (which might be interpreted as a list of abbreviations to avoid) is one way to meet thisrequirement.1.The following abbreviations are unacceptable if dictated in abbreviated form. Transcribeas follows:DICTATEDD-stickggmh.s. and/or H.S.1l/1Lkiloshydmowkq.d.cc (for liquid measurement)s.q. or subqq.o.d.sun-sat‟99mics or ugOBGYNHUIUU or ut.i.w. or stixgramgram“half-strength” and/or “at bed time”1 /subcutaneouslyevery other daySunday, Monday, Tuesday, etc.1999mcgOB/GYNHounsfield unitInternational Unitunit“3 times weekly”morphine sulfatemorphine sulfatemagnesium sulfatedischarge or discontinueleft ear / right ear / both ears3 of 2808/06/12

Abbreviations/DoseExpressionApothecary erolPhenerganThorazinehydrochloric acidCPZDPTHClHCT(if standing alone)HCTZ(if standing alone)MTXTAChydrocortisoneSee #10 belowhydrochlorothiazideSee #10 belowmethotrexatetriamcinoloneZnSO4“Nitro” dripzinc sulfatenitroglycerin infusion“Norflox”per osnorfloxacinorallyqnNightly or at bed timeqhsnightly at bedtimeq6PM, etcevery evening at 6 PMBTbedtimesssliding scale (insulin)or ½ (apothecary) and greater than and lessthanInderal 40 mgName letters anddose numbers runtogether (e.g., Inderal40 mg)MisinterpretationCorrectionMisunderstood ormisread (symbol fordram misread for “3”and minim misread for“mL”)cytarabineARAºCazathioprineUse the metric ccine)potassium chloride(The “H” ismisinterpreted as “K”)hydrochlorothiazidehydrocortisone (seeAs HCT250 mg)mitoxantroneTetracaine, Adrenalin,cocainemorphine sulfatesodiumnitroprussideinfusionNorflexThe “os” can bemistaken for “left eye”Misinterpreted as “qh”(every hour)Misread as every hourMisread as every sixhoursMistaken as “BID”(twice daily)Mistaken for “55”Mistakenly usedopposite of intendedMisread as Inderal140 mgUse the completespelling for all drugnamesUse “p.o.,” “by mouth”or “orally”Use “nightly”Use “nightly” or“nightly at bedtime”Use 6 PM “nightly”Use “at bedtime”Spell out “slidingscale” Use “one-half”or use “½”Use “greater than” or“less than”Always use spacebetween drug name,dose and unit ofmeasurement.4 of 2808/06/12

2.Do not use abbreviations within admission diagnoses, impressions, assessments,discharge diagnoses, preoperative and postoperative diagnoses or the headings ofoperations and/or procedures.3.Only use an abbreviation at the beginning of a sentence if the abbreviation begins with acapital letter.Example:Dictated:Transcribed:WBC was 9200.WBC was 9200.Dictated:Transcribed:pH was 8.4.The patient‟s pH was 8.4.4.Metric measurement should be abbreviated when preceded by a number.Examples:180 mg100 mL/ml5 cm5.Use the following abbreviations when preceded by a number.Examples:cmkgmcg6.ml/mLmEqm/secmmmgm/sSpell out an abbreviation if no number is given in conjunction with the abbreviations.Example:A few centimeters.7.Professional credentials after a person‟s name should not be transcribed with periodsbetween the letters.Examples:MDDOOTPhD8.Always use the following abbreviations EVEN WHEN dictated in mCiINTKUBaVFCATmmHgINRBUNPPDPET5 of 2808/06/12

9.10.Do not expand EKG, ECG, BNP or I&D if dictated in eponym form unless dictated in fullas there is more than one definition.Dictated:Transcribed:EKG was normal.EKG was normal.Dictated:Transcribed:ECG showed no acute change.ECG showed no acute change.Dictated:Transcribed:The patient had an I and D.The patient had an I&D.Dictated:Transcribe:The patient‟s BNP was elevatedThe patient‟s BNP was elevated.If the physician dictates HCTZ or HCT alone, ALWAYS expand. DO NOT USE THEABBREVIATION ALONE, even if the physician dictates it this way.If the physician dictates drug combination, lisinopril/HCTZ or lisinopril andhydrochlorothiazide, either/or is acceptable because it can be documented both waysand it is acceptable according to Joint Commission for the abbreviations HCTZ/HCT tobe used in combination with another drug.APOSTROPHES1.Note the correct placement of an apostrophe when expressing a time span in apossessive form.Examples:1 month‟s timean hour‟s delay2 months‟ time7 months‟ gestation2.Do not use contractions except when transcribing a quote that uses them.3.Do not use an apostrophe when using the plural form of a number, unless it is a singularnumber.Examples:The patient‟s blood sugar ran in the low 100s.His respirations stabilized in the low 20s.The patient was last seen in the 1940s.Heart rate was in the 120s.6 of 2808/06/12

4.Do not add an apostrophe to form the plural form of an abbreviation.Examples:PVCsABGsEKGs5.Use an apostrophe with a single letter abbreviation or number.Example:Serial K‟sCAPITALIZATION1.Always capitalize genus names and their abbreviated forms when they are accompaniedby a species name. Please refer to the QA bulletin board for further clarification.Examples:Campylobacter jejuniStaphylococcus aureusHelicobacter pyloriEnterococcus faecalis2.Capitalize eponyms.Examples:Parkinson diseaseCushing syndromeGram stainCoumadin3.Do not capitalize words derived from eponyms.Examples:parkinsonismcushingoid faciesgram-negativecoumadinizedcoumadinization4.Do not capitalize a noun following a trade or brand e inhalerelixir7 of 2808/06/12

5.Capitalize ethnic groups.Examples:African AmericanCaucasianHispanic6.Do not capitalize color designations.Examples:blackwhite7.Do not capitalize sexual ns do not need to be capitalized.Examples:springsummerfallwinter9.Do not capitalize the Greek alphabet.Examples:alphabetathetalamdagamma8 of 2808/06/12

COLONS1.Do not use a colon when transcribing military time.Example:The injury occurred at 1830 hours.2.3.Express ratios with Arabic numbers and a colon.Example:Dictated:Transcribed:I to E one to four.I to E (or I-to-E, I/E, I:E) ratio is 1:4Dictated:Transcribed:Epinephrine 1 to 100,000Epinephrine 1:100,000There should not be a colon next to a heading that does not have text immediatelyfollowing the heading (see Report Formatting).COMMAS1.If a dictator lists several items in a series and joins them by the word “and,” all but the lastand is to be deleted and replaced by commas. (Please reference page 90 of the AHDIStyle Guide.)Example:Dictated:Transcribed:2.The patient was on Coumadin and Inderal and digoxin and Lasix.The patient was on Coumadin, Inderal, digoxin and Lasix.Do not separate parts of a medication plan by commas.Unacceptable: The patient was discharged on prednisone 60 mg, for 3 days, 40 mg, for3 days, 20 mg, for 3 days, 10 mg, for 2 days, then off.Acceptable:The patient was discharged on prednisone 60 mg for 3 days, 40 mg for 3days, 20 mg for 3 days, 10 mg for 2 days, then off.Unacceptable: The patient was discharged on Carafate 1 gram, 4 times daily, 40minutes after meals and at bedtime, bethanechol 25 mg, p.o., q.i.d., andReglan 5 mg, at bedtime, on a trial basis.Acceptable:The patient was discharged on Carafate 1 gram 4 times daily, 40 minutesafter meals and at bedtime; bethanechol 25 mg p.o. q.i.d.; and Reglan5 mg at bedtime on a trial basis.9 of 2808/06/12

3.Use a comma after a complete date.Example:The patient was admitted on December 14, 1993, to Saint Michael Hospital.4.Do not use a comma when only the month and year have beendictated.Example:The patient was admitted in December 1993 at Saint Michael Hospital.5.Use a comma in numbers with five or more digits.Example:12,3456.Do not use a comma in a number containing a decimal point.Example:12345.677.Use a comma before and after a Latin abbreviation (and their translations), within asentence.Examples:etc.i.e.e.g.et al.viz.Her symptoms come on with exertion, for example, when climbing stairs or running.The patient was given proper instructions, i.e., a head injury sheet and a sprain injurysheet.8.Use a comma to separate city and state.Example:She was born in Columbus, Ohio, in 1954.10 of 2808/06/12

COMMONLY CONFUSED TERMSIn addition to the below, you can refer to the following for further explanations and help.Pages 511 – 525 of the AHDI 3rd Edition Book of Style for a more in depth list ofcommonly confused termsQA Team Bulletin BoardBlue Book of Grammar s-1.aspaccess – passageexcess – beyond normalaffect – as a verb, means to influence or change; as a noun, means an expressed or observedemotion or feelingeffect – as a verb, means to bring about or cause to happen; as a noun, means resultassess- to evaluateaxes – plural of axisaxis – a reference line, an artery that dividescannot - one wordcoarse – lacking refinementcourse – a path takencrepitus - the crackling sound produced by the rubbing together of bone fragments, dry synovialsurfaces of joints, discharge of flatus from bowels, crackling sounds heard in the lungs (refer tothe dictionary)crepitation – the noise made by rubbing together the ends of a fractured bonecrepitant – used as an adjective, i.e., crepitant ralescrepitance – although crepitance is not found in dictionaries, its frequent usage has made itacceptabledecubiti – not a worddecubitus – the act of lying downelicit – to bring outillicit – illegaleminent – prominent, to stand outimminent - ready to take placeen route – on the wayfascicular – a small bundlevesicular – a small cavity or cellfiancee – female engagedfiance – man engagedflare-up – sudden out breakflair-up (is not a word) – flair is a knack for somethingfollow up – (verb) we will follow up with regular return visitsfollowup – (noun) the patient did not return for followup; (adjective) in followup visits, sheappeared to improvefollow-up – the hyphenated form is an acceptable alternative to followupgap – an openinggape – to become widely open or separated, i.e., on the forehead is a 1.5-cm gaping lacerationileum – the distal portion of the small intestine, extending from the jejunum to the cecumilium – the expansive superior portion of the hip bonein situ – confined to the site of origin without invasion of neighboring tissuesit‟s - it isits - possessiveladies - plural11 of 2808/06/12