| 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...: 1 | DO NOT SPACE following a period used as a decimal point, abbreviation, apostrophe |
| I. Rules on Spacing: A. Do not type a space...: 2 | DO NOT SPACE between quotation marks and the quoted material |
| I. Rules on Spacing: A. Do not type a space...: 3 | DO NOT SPACE before or after a hyphen/slash/dash |
| I. Rules on Spacing: A. Do not type a space...: 4 | DO NOT SPACE between a number and percent sign |
| I. Rules on Spacing: A. Do not type a space...: 5 | DO NOT SPACE after opening parenthesis and before the right parenthesis |
| I. Rules on Spacing: A. Do not type a space...: 6 | DO NOT SPACE between any word and the punctuation following it. |
| I. Rules on Spacing: A. Do not type a space...: 7 | DO NOT SPACE between the number and the colon when expressing ratios 1:1 |
| I. Rules on Spacing: A. Do not type a space...: 8 | DO NOT SPACE on either side of the colon when expressing the time of day |
| I. Rules on Spacing: A. Do not type a space...: 9 | DO NOT SPACE before an apostrophe (refer to number 1) |
| I. Rules on Spacing: A. Do not type a space...: 10 | DO NOT SPACE before or after a comma used within numbers |
| I. Rules on Spacing: A. Do not type a space...: 11 | DO NOT SPACE with symbols accompanied by numbers (such as: +, -, %, #, $, @, &, =,/, degrees) |
| I. Rules on Spacing: A. Do not type a space...: 1-11 | congrats |
| I. Rules on Spacing: B. Do One space...: 1 | DO ONE between words |
| I. Rules on Spacing: B. Do One space...: 2 | DO ONE after a comma (except if used with numbers, DO NOT SPACE) |
| I. Rules on Spacing: B. Do One space...: 3 | DO ONE after a semicolon |
| I. Rules on Spacing: B. Do One space...: 4 | DO ONE after a period following an initial |
| I. Rules on Spacing: B. Do One space...: 5 | DO ONE after the closing parenthesis |
| I. Rules on Spacing: B. Do One space...: 6 | DO 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...: 1 | DO TWO after punctuation at the end of a sentence |
| I. Rules on Spacing: C. Do Two spaces...: 2 | DO TWO after a colon EXCEPT when expressing time or a dilution ratio |
| I. Rules on Spacing: C. Do Two spaces...: 1-2 | congrats |
| 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: 2 | Spell out WHOLE numbers zero through nine |
| II. Rules on Numbers: Using Arabic Numerals: 1-2 | congrats |
| 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: 9 | Use 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: 10 | Use Arabic numerals for OBSTETRIC HISTORY, APGAR SCORING, DIABETES TYPES, GRADING MURMURS |
| II. Rules on Numbers: Using Arabic Numerals: Except For: 11 | Always 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: 1-12 | congrats |
| II. Rules on Numbers: Using Roman Numerals: 1 | For Cranial nerves (CN II, III, IV) |
| II. Rules on Numbers: Using Roman Numerals: 2 | Stage of Cancer |
| II. Rules on Numbers: Using Roman Numerals: 3 | EEG leads |
| II. Rules on Numbers: Using Roman Numerals: 1-3 | congrats |
| 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: 1-2 | congrats |
| PLURAL: UNIQUE RULE:
Example | DO 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: 1 | Spell 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: 2 | Abbreviate all metric measurements |
| III. MEASUREMENTS: 3 | Use F for Fahrenheit IF accompanied by the symbol for degree |
| III. MEASUREMENTS: 4 | Spell out Fahrenheit IF degree is spelled out.
98.6 degrees Fahrenheit |
| III. MEASUREMENTS: 5 | Use C for Celsius IF accompanied by the symbol for degree. 36(degree symbol) C |
| III. MEASUREMENTS: 6 | Spell out Celsius IF degree is spelled out. 36 degrees Celsius |
| III. MEASUREMENTS: 1-6 | congrats |
| IV. SYMBOLS: 1 | Spell out a symbol when used alone (with no number). |
| IV. SYMBOLS: 2 | Use symbols when they are used with numbers. |
| IV. SYMBOLS: 1-2 | congrats |
| V. CAPITALIZATION: Do Capitalize...: 1 | The first word following a colon if it begins a complete sentence or is part of an outline entry |
| V. CAPITALIZATION: Do Capitalize...: 2 | The first letter of chemical elements |
| V. CAPITALIZATION: Do Capitalize...: 3 | The names of the days of the week, months, holidays, historic events, and religious festivals |
| V. CAPITALIZATION: Do Capitalize...: 4 | The names of specific departments or sections in the institution only when the institution name is included |
| V. CAPITALIZATION: Do Capitalize...: 5 | The names of diseases that include PROPER NOUNS, EPONYMS OR GENUS NAMES |
| V. CAPITALIZATION: Do Capitalize...: 6 | The trade or brand names of drugs |
| V. CAPITALIZATION: Do Capitalize...: 7 | The names of races, language, people, and religions |
| V. CAPITALIZATION: Do Capitalize...: 1-7 | congrats |
| V. CAPITALIZATION: Do Not Capitalize...: 1 | The spelled out names of the chemical elements |
| V. CAPITALIZATION: Do Not Capitalize...: 2 | The seasons of the year |
| V. CAPITALIZATION: Do Not Capitalize...: 3 | The common names of diseases |
| V. CAPITALIZATION: Do Not Capitalize...: 4 | The names of viruses unless they include a proper noun |
| V. CAPITALIZATION: Do Not Capitalize...: 5 | Generic drug names |
| V. CAPITALIZATION: Do Not Capitalize...: 6
Example: | The common noun following the brand name.
Example - Tylenol tablets |
| V. CAPITALIZATION: Do Not Capitalize...: 7 | The names of medical or surgical specialties |
| V. CAPITALIZATION: Do Not Capitalize...: 8 | Designations based on skin color, like "a tall white man". |
| V. CAPITALIZATION: Do Not Capitalize...: 1-8 | congrats |
| VI. CANCER CLASSIFICATIONS: 1 | Stage and grade- do not capitalize either one if it does not being a sentence. |
| VI. CANCER CLASSIFICATIONS: 2 | Use Roman numerals for cancer stages |
| VI. CANCER CLASSIFICATIONS: 3 | Use Arabic numerals for cancer grades |
| VI. CANCER CLASSIFICATIONS: 4 | For clarity, use capital letters or Arabic suffixes without spaces or hyphens. |
| VI. CANCER CLASSIFICATIONS: 1-4 | congrats |
| VII. DRUG TERMINOLOGY: 1 | If dictated q.day - transcribe q.d. |
| VII. DRUG TERMINOLOGY: 2 | If 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: 1-4 | congrats |
| 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: 1-2 | congrats |
| 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: 1-2 | congrats |
| X. REPORT SECTION NOTES: 1 | Capitalize brand name medications. DO NOT CAPITALIZE generic medications |
| X. REPORT SECTION NOTES: 2 | Use 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: 4 | When 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: 1-5 | congrats |
| 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 |
