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Commonly used Transcription rules

     

1

Spacing With Punctuation Marks

   

    Do Not Type a Space ...
  • before or after a hyphen
  • before or after a slash
  • before or after a dash
  • between a number and percent sign
  • between parentheses and the enclosed material
  • between any word and the punctuation following it.
  • between the number and the colon used to indicate a dilute solution or ratio, e.g. 1:4
  • on either side of the colon when expressing the time of day
  • before an apostrophe
  • before or after a comma used within numbers
  • before or after an ampersand in abbreviations, e.g., C&S
  • on either side of the colon when expressing ratios e.g. 1:1
  • after the closing parenthesis if another mark of punctuation follows
  • when using the word “times” as x – e.g., x3

    Type One Space...

  • between words
  • after a comma
  • after a semicolon
  • after a period following an initial
  • after the closing parenthesis
  • on each side of the x in an expression of dimension, e.g. 4 x 4 type 2 spaces...
  • after punctuation at the end of a sentence
  • after a colon except when expressing time or a dilution ratio

2

Numbers

   
  • Spell out WHOLE numbers zero through nine, use numerals for 10 and above (this may change in the near future as the AAMT is trying to standardize using numerals only.
  • Use numerals when numbers are directly used with symbols.
  • Use numerals when expressing ages.
  • If it is an approximate age, spell it out.
  • Use numerals to express size and measurements.
  • Use numerals for everything metric. Centimeters, millimeters, liters, etc.
  • Use numerals in all expressions pertaining to drugs - this includes strength, dosage and directions. Z-PAK 2 daily on day 1, then 1 daily on days 2-5.
  • Spell out and hyphenate fractions standing alone. He drank one-half a gallon of apple juice.
  • Use numerals to express mixed fractions. 1 1/2 years.
  • Use commas only if there are 5 or more digits when expressing numbers. e.g. 10,000, 4000.
  • Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration.
  • Substitute a hyphen for the word "to". He is to take 1-2 tablets of Tylenol every 4-6 hours p.r.n.
  • Leave a space between numerals and measurements unless they form a compound modifier. It is 6 cm below the ...... It is 1200 mL....... A 4-cm nevus....... A 2 x 2-mm lesion.......
  • Always use 0 in front of the decimal point if the number is not a whole number. 0.75 mg
  • Use decimal fractions with metric measurements. 1.5 cm
  • Use mixed fractions with English system measurements. 1 1/2 inch
  • Use numerals for: Ages, units of measure, vital statistics, lab values and in other instances where it is important to communicate clearly the number referenced. Examples: 4 inches, 3-year-old. She has three dogs who have eight fleas each. A total of 7 basal cell carcinomas removed from his left arm. (7 for clarity)
  • Do not start a sentence using a number. Spell out the number or recast the sentence.
  • Dictated as: 10 milligrams of Reglan was administered stat. Transcribe as: Reglan 10 mg was administered stat.
  • Exception - It is acceptable to begin a sentence with a date. Example - 2004 is going to be a prosperous year.
  • Plurals - do not use an apostrophe to form plural numbers.
  • 4 x 4s
  • She was in her 20s or twenties (this is acceptable because it is not a definite number).
  • She was born in the 1970s.
  • Series of numbers - Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction.
  • Example - Jeff has 1 job, 1 place of employment and 18 hours a day to do the work.
  • Cranial nerves - Preferred: Roman numerals I-XII
  • Diabetes type 1 and type 2, not Roman numerals I and II - this was recently standardized by the American Diabetes Association.
  • Apgar scores - Use numerals for ratings and spell out numbers relating to minutes. Rationale - to draw attention to the scores. Example: The Apgar scores were 6 and 9 at one and five minutes. Apgar is not an acronym.

  • Time Examples
  • 8:30 a.m. - morning
  • 8:30 p.m. - evening
  • noon, not 12:00 noon
  • midnight, not 12:00 midnight or 12 'o'clock or 12:00 p.m.

3

Measurements

   
  • Spell out all nonmetric measurements. Feet, inches, pounds, ounces, yards, grain, dram, etc.

  • Exceptions:
  • Use tsp for teaspoon
  • Use tbsp for tablespoon
  • Abbreviate all metric measurements.
  • Use F for Fahrenheit IF accompanied by the symbol for degree. 98.6°F
  • Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit.
  • Use C for Celsius IF accompanied by the symbol for degree. 36°C
  • Spell out Celsius IF degree is spelled out. 36 degrees Celsius.

  • In tables and technical documents:
  • Use ft or ' for feet
  • Use " for inches
  • Use yd for yard
  • Use pt for pint
  • Use oz for ounce
  • Use fl oz for fluid ounce

  • Abbreviate most unusual units of measure when accompanied by numerals Dictated as Transcribed as:

  • 0.8 centimeters squared 0.8 sq cm
  • 22 millimeters of mercury 22 mmHg
  • 3.0 liters per minute 3.0 L/min
  • 40 millimeters per hour 40 mm/h
  • 8 grams percent 8 gm%

4

Symbols

   
  • Spell out a symbol when used alone (with no number).
  • Use symbols when they are used with numbers
  • Common Symbols

    Dictated as Transcribed as:
  • Four to five 4-5
  • Number 3 0 #3-0
  • Twenty-twenty vision 20/20
  • BP 120 over 80 120/80
  • Grade two over six 2/6
  • A positive A+
  • Three point five centimeters 3.5 cm
  • Point five centimeters 0.5 cm

5

Capitalization

   

    Capitalize...

  • Abbreviations when the words they represent are capitalized
  • The first word following a colon if it begins a complete sentence or is part of an outline entry
  • Most abbreviations of English words
  • The first letter of chemical elements
  • The names of the days of the week, months, holidays, historic events and religious festivals
  • The names of specific departments or sections in the institution only when the institution name is included
  • The names of diseases that include proper nouns, eponyms or genus names
  • The trade or brand names of drugs
  • A quote when it is a complete sentence
  • The names of races, peoples, religions and languages. Black, as a race designation would be capitalized, however client preferences may differ.

    Do Not Capitalize...
  • The spelled out names of the chemical elements
  • The seasons of the year
  • The common names of diseases
  • The names of viruses unless they include a proper noun
  • Generic drug names
  • The common noun following the brand name. Example - Tylenol tablets
  • The names of medical or surgical specialties
  • Designations based on skin color, like "a tall white man."

6

Hyphenation

   
  • These prefixes do not require the use of a connecting hyphen in compound terms:
  • ante intra semi
  • anti micro sub
  • bi mid super
  • co non supra
  • contra over trans

7

Stage, Type, and Fracture Classifications

   
  • Lowercase the words "stage" and "type," and use roman numerals. For subdivisions of stages, follow The AAMT Book of Style rules for cancer classifications, and add on-line capital letters without spaces or hyphens:
  • Examples
  • complex regional pain syndrome stage I
  • stage II-III
  • type I radioulnar synostosis
  • type II open fracture
  • type IIIB
  • Garden II femoral neck fracture
  • Salter VI fracture

8

Grade

   
  • Lowercase the word "grade" and use arabic numerals:
  • Examples:
  • grade 1 chondromalacia patellae
  • grade 2
  • grade 3-4

9

Level, Phase, and Class

   
  • Lowercase the words "level," "phase," and "class," and use arabic or roman numerals according to the system being referenced:
  • Examples:
  • Radiation Therapy Oncology phase III
  • Haggitt level 4 colorectal adenocarcinoma
  • physical status class 2E

10

Wrist Arthroscopy Portals

   
  • Use arabic numerals. Two numbers should be hyphenated without spaces; add on-line capital letters with no space:
  • Examples:
  • 1-2 portal
  • portal 3-4
  • 6U wrist portal

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Common Transcription Rules






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