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level: Basic Rules of Transcription: Instructional

Questions and Answers List

level questions: Basic Rules of Transcription: Instructional

QuestionAnswer
I. Rules on Spacing: A, B, and C:A. Do not type a space... B. Do One Space... C. Do Two Spaces...
I. Rules on Spacing: A. Do not type a space...: 1DO NOT SPACE following a period used as a decimal point, abbreviation, apostrophe
I. Rules on Spacing: A. Do not type a space...: 2DO NOT SPACE between quotation marks and the quoted material
I. Rules on Spacing: A. Do not type a space...: 3DO NOT SPACE before or after a hyphen/slash/dash
I. Rules on Spacing: A. Do not type a space...: 4DO NOT SPACE between a number and percent sign
I. Rules on Spacing: A. Do not type a space...: 5DO NOT SPACE after opening parenthesis and before the right parenthesis
I. Rules on Spacing: A. Do not type a space...: 6DO NOT SPACE between any word and the punctuation following it.
I. Rules on Spacing: A. Do not type a space...: 7DO NOT SPACE between the number and the colon when expressing ratios 1:1
I. Rules on Spacing: A. Do not type a space...: 8DO NOT SPACE on either side of the colon when expressing the time of day
I. Rules on Spacing: A. Do not type a space...: 9DO NOT SPACE before an apostrophe (refer to number 1)
I. Rules on Spacing: A. Do not type a space...: 10DO NOT SPACE before or after a comma used within numbers
I. Rules on Spacing: A. Do not type a space...: 11DO NOT SPACE with symbols accompanied by numbers (such as: +, -, %, #, $, @, &, =,/, degrees)
I. Rules on Spacing: A. Do not type a space...: 1-11congrats
I. Rules on Spacing: B. Do One space...: 1DO ONE between words
I. Rules on Spacing: B. Do One space...: 2DO ONE after a comma (except if used with numbers, DO NOT SPACE)
I. Rules on Spacing: B. Do One space...: 3DO ONE after a semicolon
I. Rules on Spacing: B. Do One space...: 4DO ONE after a period following an initial
I. Rules on Spacing: B. Do One space...: 5DO ONE after the closing parenthesis
I. Rules on Spacing: B. Do One space...: 6DO ONE on each side of the x in an expression of dimension, e.g. 4 x 4
I. Rules on Spacing: B. Do One space...: 1-6:Congratulations
I. Rules on Spacing: C. Do Two spaces...: 1DO TWO after punctuation at the end of a sentence
I. Rules on Spacing: C. Do Two spaces...: 2DO TWO after a colon EXCEPT when expressing time or a dilution ratio
I. Rules on Spacing: C. Do Two spaces...: 1-2congrats
II. Rules on Numbers: on what and how many numerals:on 3 Numerals, namely: Arabic Numerals Roman Numerals Ordinal Numerals
II. Rules on Numbers: Using Arabic Numerals: 1 Example:Spell out FRACTIONS standing alone Example: He drank one-half a gallon of apple juice.
II. Rules on Numbers: Using Arabic Numerals: 2Spell out WHOLE numbers zero through nine
II. Rules on Numbers: Using Arabic Numerals: 1-2congrats
II. Rules on Numbers: Using Arabic Numerals: Except For: 1 Example:Use Arabic numerals when expressing AGES. Example: A 2-year-old boy was rushed to the emergency room
II. Rules on Numbers: Using Arabic Numerals: Except For: 2 Example:Use Arabic numerals for DATES Example: The patient was first seen in the emergency department on 'March 3, 1965'
II. Rules on Numbers: Using Arabic Numerals: Except For: 3 Example:Use Arabic numerals in writing numbers containing DECIMAL FRACTIONS Example: There was a 3.5 cm cut above the left eyebrow
II. Rules on Numbers: Using Arabic Numerals: Except For: 4 Example:Use Arabic numeral for DIMENSIONS, SIZES, AND MEASUREMENTS Example: A 12 x 14 feet area A 4 cm tear on the forehead
II. Rules on Numbers: Using Arabic Numerals: Except For: 5 Example:Use Arabic numerals in all expressions pertaining to DRUGS OR MEDICATIONS. This includes strength, dosage, and directions. Example: The direction of her Motrin were 400 mg q.4h. p.r.n. pain
II. Rules on Numbers: Using Arabic Numerals: Except For: 6 Example:Use Arabic numerals to write MIXED NUMBERS Example: Mr. XYZ moved to this community 2-1/2 years ago.
II. Rules on Numbers: Using Arabic Numerals: Except For: 7 Example:Use Arabic numerals 10 and above. When there is five or more digits presented use a comma: Example: The culture grew 100,000 colonies of E. coli per cubic centimeter
II. Rules on Numbers: Using Arabic Numerals: Except For: 8 Example:Use Arabic numerals for LABORATORY TEST RESULTS OR VALUES Example: RBCs: 3,210,000; WBCs 7700
II. Rules on Numbers: Using Arabic Numerals: Except For: 9Use Arabic numerals when expressing VITAL STATISTICS AND VITAL SIGNS (such as: height, weight, blood pressure, pulse, and respiration)
II. Rules on Numbers: Using Arabic Numerals: Except For: 10Use Arabic numerals for OBSTETRIC HISTORY, APGAR SCORING, DIABETES TYPES, GRADING MURMURS
II. Rules on Numbers: Using Arabic Numerals: Except For: 11Always use 0 in front for the decimal point if the number is not a whole number
II. Rules on Numbers: Using Arabic Numerals: Except for: 12 Examples:Except For: Use Arabic numerals when numbers are directly used with symbols (such as: +, -, %, #, $, @, &, =, /, and degrees) Examples: Pulses were 2+ 45.5% Temperature: 36 (insert symbol degrees Celsius) Blood pressure: 100/80 1+ protein
II. Rules on Numbers: Using Arabic Numerals: Except for: 1-12congrats
II. Rules on Numbers: Using Roman Numerals: 1For Cranial nerves (CN II, III, IV)
II. Rules on Numbers: Using Roman Numerals: 2Stage of Cancer
II. Rules on Numbers: Using Roman Numerals: 3EEG leads
II. Rules on Numbers: Using Roman Numerals: 1-3congrats
II. Rules on Numbers: Using Ordinal Numerals: 1 Example:Spell out ordinal numbers when used to indicate a TIME SEQUENCE Example: This is her second visit to the clinic He was discharged on the third day of hospitalization
II. Rules on Numbers: Using Ordinal Numerals: 2 Example:Use numbers for ordinals pertaining to RIBS, NAMES, BURN DEGREE, and SPINE Example: The 5th and 6th ribs were fractured James Smith II 3rd degree burn There was an injury between the 1st and 2nd cervical vertebrae
II. Rules on Numbers: Using Ordinal Numerals: 1-2congrats
PLURAL: UNIQUE RULE: ExampleDO NOT USE APOSTROPHE for plural form on ABBREVIATIONS AND NUMERS The TMs were intact There were no 4 x 4s left in the box
III. MEASUREMENTS: 1Spell out all nonmetric measurements. Foot, inches, pounds, ounces, yards, grain, gram, yard, pint, quarts, galloon.
III. MEASUREMENTS: 1: Exceptions:Use tsp for teaspoon; and Use tbsp for tablespoon
III. MEASUREMENTS: 2Abbreviate all metric measurements
III. MEASUREMENTS: 3Use F for Fahrenheit IF accompanied by the symbol for degree
III. MEASUREMENTS: 4Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit
III. MEASUREMENTS: 5Use C for Celsius IF accompanied by the symbol for degree. 36(degree symbol) C
III. MEASUREMENTS: 6Spell out Celsius IF degree is spelled out. 36 degrees Celsius
III. MEASUREMENTS: 1-6congrats
IV. SYMBOLS: 1Spell out a symbol when used alone (with no number).
IV. SYMBOLS: 2Use symbols when they are used with numbers.
IV. SYMBOLS: 1-2congrats
V. CAPITALIZATION: Do Capitalize...: 1The first word following a colon if it begins a complete sentence or is part of an outline entry
V. CAPITALIZATION: Do Capitalize...: 2The first letter of chemical elements
V. CAPITALIZATION: Do Capitalize...: 3The names of the days of the week, months, holidays, historic events, and religious festivals
V. CAPITALIZATION: Do Capitalize...: 4The names of specific departments or sections in the institution only when the institution name is included
V. CAPITALIZATION: Do Capitalize...: 5The names of diseases that include PROPER NOUNS, EPONYMS OR GENUS NAMES
V. CAPITALIZATION: Do Capitalize...: 6The trade or brand names of drugs
V. CAPITALIZATION: Do Capitalize...: 7The names of races, language, people, and religions
V. CAPITALIZATION: Do Capitalize...: 1-7congrats
V. CAPITALIZATION: Do Not Capitalize...: 1The spelled out names of the chemical elements
V. CAPITALIZATION: Do Not Capitalize...: 2The seasons of the year
V. CAPITALIZATION: Do Not Capitalize...: 3The common names of diseases
V. CAPITALIZATION: Do Not Capitalize...: 4The names of viruses unless they include a proper noun
V. CAPITALIZATION: Do Not Capitalize...: 5Generic drug names
V. CAPITALIZATION: Do Not Capitalize...: 6 Example:The common noun following the brand name. Example - Tylenol tablets
V. CAPITALIZATION: Do Not Capitalize...: 7The names of medical or surgical specialties
V. CAPITALIZATION: Do Not Capitalize...: 8Designations based on skin color, like "a tall white man".
V. CAPITALIZATION: Do Not Capitalize...: 1-8congrats
VI. CANCER CLASSIFICATIONS: 1Stage and grade- do not capitalize either one if it does not being a sentence.
VI. CANCER CLASSIFICATIONS: 2Use Roman numerals for cancer stages
VI. CANCER CLASSIFICATIONS: 3Use Arabic numerals for cancer grades
VI. CANCER CLASSIFICATIONS: 4For clarity, use capital letters or Arabic suffixes without spaces or hyphens.
VI. CANCER CLASSIFICATIONS: 1-4congrats
VII. DRUG TERMINOLOGY: 1If dictated q.day - transcribe q.d.
VII. DRUG TERMINOLOGY: 2If dictated q. four hours - transcribed as q.4h. not q. 4 hours
VII. DRUG TERMINOLOGY: 3 Example: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.
VII. DRUG TERMINOLOGY: 4 Example: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 - If 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.
VII. DRUG TERMINOLOGY: 1-4congrats
VIII. LAB TEST PUNCTUATION GUIDELINES: 1 Examples: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 bases. -Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100 and glucose of 80.
VIII. LAB TEST PUNCTUATION GUIDELINES: 2 Example:Use periods to separate unrelated laboratory test results. For example: Potassium 3.7. TSH 1.0. Albumin 4.0.
VIII. LAB TEST PUNCTUATION GUIDELINES: 1-2congrats
IX. NAMES: 1 Example:Names with junior or senior attached. Use a comma before and a period after the abbreviation or use neither. Example: Jeremiah Johnson, Jr. Jeremiah Johnson Jr Not: Jeremiah Johnson, Jr or Jeremiah Johnson Jr.
IX. NAMES: 2 Example:Names with ordinals. Do not use comma between name and ordinal Example: Bernie Schwartz III Not: Bernie Schwartz, III
IX. NAMES: 1-2congrats
X. REPORT SECTION NOTES: 1Capitalize brand name medications. DO NOT CAPITALIZE generic medications
X. REPORT SECTION NOTES: 2Use Latin drug abbreviations
X. REPORT SECTION NOTES: 3 Example:Don't mix Latin and English terminology Example: If dictated q. day - transcribe q.d. NOT q. day
X. REPORT SECTION NOTES: 4When referring to strength, dosage, and directions - Use Arabic numerals only.
X. REPORT SECTION NOTES: 5 Example: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. (refer to medications rules) Example: Dictated as Synthroid point 75 milligrams a day. Transcribe Synthroid 0.75 mg q.d.
X. REPORT SECTION NOTES: 1-5congrats
XI. MEDICAL REPORTS: Example:DO NOT abbreviate diseases or condition under the heading of ASSESSMENT/DIAGNOSIS/IMPRESSION Example: If the doctor dictates CAD under DIAGNOSIS: Coronary artery disease.
XII. MISCELLANEOUS: Examples:Keep logically connected items on the same line. Drug doses, names, dates, sets, etc. Examples: -Lopressor 100 mg. Keep all 2 items on the same line. -Dr. Fred Farnswroth. Keep the doctors title and full name on the same line. -January 14, 2000. Keep the entire date on the same line. -100 pounds. Keep both words on the same line. -5 inches