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TRANSCRIPTION RULES
The following section is not intended to be a complete list of rules, but it includes most of the general
rules necessary in medical transcription. Different texts give different rules for punctuation, so it is
recommended that you follow the guidelines of the American Association of Medical Transcription
(AAMT), the source of these rules.
Abbreviations When you use abbreviations in medical documents, your reader must be able to
recognize or translate the abbreviation.
Every licensed medical facility is required to keep a list of approved abbreviations, and this list should be
updated regularly. Some facilities have local abbreviations that are specific to the facility. Like words in
English, many abbreviations have two meanings. The use of capital letters can change the meaning
entirely. For example, CC means chief complaint, but cc means cubic centimeters. For this reason, be
very cautious in using abbreviations. Some abbreviations have become accepted because they are used
more than the long form. BP has come to be easily recognized as blood pressure when used in the vital
sign section of the report. In a hospital setting, the use of abbreviations in typed reports is forbidden. For
example, you are not allowed to abbreviate the diagnosis on an operative report.
Most doctors’ offices use standard abbreviations in the patients’ charts, but when you are typing a formal
report, it is risky to use abbreviations. If it is the policy of your facility to use abbreviations in letters and
formal reports, spell out the words the first time the abbreviation is used, with the abbreviation following in
parentheses. In general, “when in doubt, spell it out.”
Capitalization Knowing when to capitalize and when to use lowercase letters is a mark of an excellent
transcriptionist. The rules about using capital letters you learned in grammar school still apply, but when
you are transcribing medical records, capitals are used in additional situations.
Use capital letters:
1. For headings.
CHIEF COMPLAINT or Chief Complaint
2. For eponyms (terms formed using the name of a person, usually the name of the researcher or
physician who identified a disorder or the inventor of equipment, instruments, supplies, and so
on), the second word in the phrase is not capitalized. Note: Recent revisions in punctuation
guidelines eliminate the possessive apostrophe.
Crohn’s disease Foley catheter Down syndrome Healy clamp
3. For trade or brand names of drugs and products. Do not capitalize generic names of drugs and
products.
diazepam Valium tissue Kleenex
4. For the genus of an organism. An example of this classification system of living organisms is
Staphylococcus aureus. Staphylococcus is the genus and aureus is the species. A singular genus
is capitalized and italicized. If the genus is plural or used as an adjective, it is lower case and not
italicized. Use lowercase letters and italics for the species.
as noun: Staphylococcus aureus as adjective: staphylococcal infection
5. For a department name when the name is the proper title of a place, but not for department
names within a facility.
The patient was taken to the emergency room.
The patient was taken to the Forsyth Medical Center Emergency Room.
6. For proper names of languages, races, and religions.
She is a 23-year-old Hispanic woman.
Do not capitalize informal designations such as white or black.
7. For acronyms (words formed from initials of words in a phrase).
NKDA (no known drug allergies) CABG (coronary artery bypass graft)
8. To draw attention to vital information, such as allergies.
ALLERGIES: The patient is allergic to PENICILLIN.
Numbers Traditional office technology courses teach the rules for using numbers, but many of those
rules do not apply to medical documents. When those guidelines have the potential to cause confusion or
harm a patient, you must be flexible enough to bend them. The safety of the patient is a goal of the
transcriptionist.
Follow these guidelines for using numbers in medical reports:
1. Spell out the numbers one through nine in a narrative report. Ten and above are keyed as
numerals (e.g., 10, 11) unless they begin a sentence, as in this sentence.
2. If you are using two numbers in one sentence, be consistent.
It does not matter whether you choose numerals or words, but they should be consistent.
Dr. Smith saw 14 patients today; one of them was only 2 days old.
If using more than one number could cause confusion, spell out the one that is easiest and
shortest.
The patient states that she drinks 12 two-liter sodas per week.
Chapter 9 ■ Transcription 171
3. Always use numerals with symbols. Do not key a space between the number and the symbol.
100% oxygen $14.27 balance due _2 specimen
4. For balance and clarity, add a zero before and after a decimal point. The provider will say, “The
specimen measures eight by five and a half by point six.” Clear: The specimen measures 8.0 _
5.5 _ 0.6.
Unclear: The specimen measures 8 _ 5.5 _ .6.
5. Key a space between numerals and a unit of measurement, abbreviation, or symbol.
10 mg% 40 mL 20 mm Hg
6. Use numerals for measurements of vital signs, laboratory values, age, height, weight, and so
on.
BP 110/70 Respirations 20 Temperature 98.7_F Wt. 140 lb.
Pulse 80 Ht. 60 inch.
FBS (fasting blood sugar) 98
7. Spell out ordinal numbers except in dates.
She began feeling better the third day after surgery.
The patient was seen on May 3.
8. Roman numerals are used with cranial nerves, obstetric history, electrocardiographic leads,
types and factors, and cancer stages.
Cranial nerves II through XII are intact.
Limb leads II through V on the electrocardiogram were not making contact.
The carcinoma is stage II.
Punctuation One of the most important skills necessary to be an efficient and productive
transcriptionist is the ability to punctuate without direction. Some physicians dictate punctuation, but you
should not automatically type these directions unless they follow the AAMT’s Guidelines for Transcription.
Apostrophes Use an apostrophe:
1. To show possession The patient’s appointment is Wednesday.
2. To form contractions She’s having flu symptoms. (The apostrophe contracts she and is.) Note:
“It is” can be shortened to “it’s,” but there is no apostrophe in the possessive: Its length is 4 cm.
3. With units of time and money when they are possessive We will give him a week’s worth of
medication.
Nine months’ gestation is standard.
He bought 10 dollars’ worth of gas.
4. For clarity when using one letter as a word The I’s were not dotted.
But not to form plurals DRGs WBCs I’ve had this dress since the 1970s.
Unless it is possessive The CMA’s uniform is neat and clean.
Commas Use a comma:
1. Between items in a series (the last comma is optional).
The patient is alert, oriented and talkative.
Or The pain is bilateral, severe, and stabbing.
Note: Do not use commas between items that modify each other. Even though this seems like a
series of adjectives, it is really one unit.
There is severe, stabbing, bilateral pain in the lower abdominal region.
The first three adjectives modify pain and are separated by commas. “Lower” refers to the
abdomen, not the region, so no comma is used.
2. To link two complete sentences that are separated by a conjunction.
She is a very sick patient, and I will admit her immediately.
But not when both clauses lack a subject and a predicate She is a very sick patient and needs to
be admitted.
“Needs to be admitted” does not contain its own subject.
Therefore, no comma is needed.
3. After the conjunctive adverb.
The medical assistant is in great demand; therefore, most schools have a waiting list.
4. After an introductory phrase or clause with a subject and a verb.
After she has her chest radiograph, she will come back to the office.
NO comma is needed when the sentence is reversed.
She will come back to the office after she has her chest x-ray.
Lightheaded, she sat down on the floor.
5. To set off clauses within a sentence that provide additional information.
Electroencephalography, a test that assesses the electrical activity in the brain, is a diagnostic
tool used by neurologists.
6. To set off parenthetical expressions.
The pain, according to the patient, measures 10 on the pain scale.
172 Section II ■ The Administrative Assistant Chapter 9 ■ Transcription 173 7. With dates when using the
year, place names, and long numbers.
The patient was seen last on May 2, 2003.
But: The patient was seen last on May 2 at 2:00 P.M.
Duke University Medical Center is in Durham, North Carolina.
7. Numbers over six figures: 4500 567,158,230 8. With quotations.
The patient said, “I will quit smoking tomorrow.” 9. To prevent confusion.
“The physician came in, in order to see the patient.”
Semicolons Use a semicolon:
1. To separate main clauses that do not have a conjunction such as and or but The patient
arrived 10 minutes late; she had car trouble.
2. To separate two main clauses if they are long or you need other commas within the sentence
She had chest pain, nausea, and headache; and her daughter took her to the emergency room.
Colons Use a colon:
1. After headings FAMILY HISTORY: The patient reports no family history of cancer.
2. To introduce a series after a complete clause but not after a verb The physician prescribed the
following medications: Keflex, Darvocet-N 100, K Tabs and Prinivil.
The physician prescribed Keflex, Darvocet-N 100, K-Tabs, and Prinivil.
3. To separate hours from minutes Your appointment is scheduled for 10:30 A.M.
4. After a salutation in a business letter Dear Dr. Johnsen:
Periods In addition to ending sentences, periods are used:
1. With lowercase abbreviations a.m., p.m. But: AM, PM PhD Metric measurements do not use
periods.
They had to remove 3 ft. of her colon.
We removed 15 mL of pleural fluid.
2. After an abbreviation that is a shortened part of a word American Association of Medical
Assistants, Inc.
3. After a person’s initials J. T. Weaver, MD
Quotation Marks Quotation marks enclose:
1. A direct quotation The patient stated, “My friend recommended your office to me.”
2. Words that are slang or thought to be a quotation.
The patient stated he was “blown away” by his improved cholesterol reading.
Jessica thinks her new boyfriend is “Prince Charming.”
3. Titles of articles, short stories, subdivisions, and so on Please read “Making the Patient
Comfortable” in the most recent issue of our professional journal.
Slash Marks In medical transcription, the slash mark is used:
1. In place of the word per. The provider says, “Give the patient one hundred percent oxygen at
two liters per minute.” You type: Give the patient 100% oxygen at 2 liters/minute.
In some cases, the provider may not say “for,” but you insert a slash.
The student took the class on a pass/fail basis.
2. To separate options and alternatives.
This is a pass/fail course.
Hyphens Hyphens are used:
1. In compound words. The general rule is that when two words are used together to form a word,
they are joined by a hyphen. Many compound nouns have been used long enough to be
consolidated and are now accepted words in their own right. For example, spread-sheet has
become spreadsheet.
mother-in-law figure-of-eight sutures
2. A hyphen can clear up confusion or ambiguity. For example, re-creation is quite different from
recreation.
Without the hyphen, the reader would misinterpret the meaning.
We will re-treat with a different antibiotic.
As opposed to We went on a weekend retreat.
174 Section II ■ The Administrative Assistant
3. When joining the two words would result in two or more identical letters.
post-traumatic pre-enteric pre-existing Note: Otherwise, the hyphen is not used with these
prefixes.
postoperative infection prehistoric
4. When spelling out the compound numbers twenty-one to ninety-nine.
Fifty-eight percent of our patients are over sixtyfive years old.
5. When using compound adjectives before a noun.
high-frequency hearing loss well-developed frame 22-gauge needle 6-month-old infant
Remember, the hyphen is not used when the compound adjective follows the noun it modifies:
The patient is 6 months old.
6. The hyphen is not used when adverbs modify adjectives.
very high fever quickly spreading cancer
7. When a compound adjective contains the suffix -free.
symptom-free
8. When the compound includes an acronym.
post-CABG care pre-ICU lab results
9. When keying suture sizes.
2-0 Prolene
Grammar When a physician dictates a report using incorrect grammar, it is your job to correct the
mistake. The physician expects you to produce an error-free report, even though he or she may overlook
basic parts of speech and rules of sentence grammar. Although a thorough discussion of the grammar
rules in the English language is outside the scope of this text, some basic rules should be mentioned. The
most common errors made in medical transcription are those dealing with verb tense.
Always be sure that subjects and verbs agree in number.
One patient: The patient is alert.
More than one vital sign: His vital signs are normal Always make sentences within a paragraph agree in
tense and subject. Suppose the provider dictates, “The patient was seen in clinic today for pain in the left
knee. The examination is negative.” You will key, “The patient was seen in clinic today for pain in the left
knee. The examination was negative.”
Spelling When in doubt about the spelling of a word or drug, always use a reference book, dictionary,
or spell check to confirm the spelling. Keep in mind that computer spell check will check for spelling only,
and a misused word will not be caught if it is spelled correctly. For example, “the patient was late four his
appointment” will pass the spell check because “four” is spelled correctly, even though the transcriptionist
meant to key “for.” Here are some basic spelling tips:
1. I comes before e except after c or when sounded like a as in neighbor and weigh.
Examples: achieve, receive (the exceptions are either, neither, weird, leisure, and conscience)
2. For words ending in ie, drop the e and change the i to y before adding ing.
Examples: die, dying; lie, lying
3. Words ending in o that are preceded by a vowel are made plural by adding s.
Examples: studio, studios; trio, trios Words ending in o that are preceded by a consonant form the
plural by adding es.
Examples: hero, heroes; potato, potatoes
4. Words ending in y preceded by a vowel form the plural by adding s.
Examples: attorney, attorneys; day, days Words ending in y that are preceded by a consonant
change the y to i and add es.
Examples: berry, berries; lady, ladies
5. The final consonant of a one-syllable word is doubled before adding a suffix beginning with a
vowel.
Examples: pin, pinning; run, running If the final consonant is preceded by another consonant or
by two vowels, do not double the consonant.
6. Words ending in a silent e generally drop the e before adding a suffix beginning with a vowel.
Examples: ice, icing; judge, judging The exceptions are dye, eye, shoe, and toe. The e is not
dropped in suffixes beginning with a consonant, however, unless another vowel precedes the
final e.
Examples: argue, argument; pale, paleness
7. For all words ending in c, insert a k before adding a suffix beginning with e, i, or y.
Examples: picnic, picnicking; traffic, trafficker
You must pay close attention to spelling when transcribing medical documents. Remember, in the
medical world a misspelled drug or word can be dangerous.
From: Lippincott Williams & Wilkins