Medical Report Writing Guidelines

Questions and Answers

What is the correct format for a date dictated as "June of last year"?

06/01/YYYY

06/DD/YYYY (correct)

06/DD/2022

June YYYY

In which section of the report should abbreviations be expanded?

Name of Procedure

History and Physicals

Assessment

All of the above (correct)

What is the correct way to transcribe the abbreviation "C-section" in the "Operative Procedure" section?

C-section

Cesarean

C Section

Cesarean Section (correct)

Which of the following is an example of a dangerous abbreviation that should be corrected?

U Signup and view all the answers

What is the correct way to transcribe the dictation "[Name]" in the report?

[Name] Signup and view all the answers

When should a new report be submitted?

After completing a report Signup and view all the answers

What should be done with self-graded reports before starting a new report?

Graded and submitted Signup and view all the answers

Which of these is NOT a type of work that needs to be transcribed?

Laboratory Reports Signup and view all the answers

How should the abbreviation for grams be correctly written?

g Signup and view all the answers

Which of the following is the correct format for time notation?

12 p.m. Signup and view all the answers

When representing liters of oxygen, which format is correct?

3L of oxygen Signup and view all the answers

How should the term 'plus' be represented when not clear in meaning?

plus Signup and view all the answers

What is the correct way to represent the word 'times' when dictating before a number?

x Signup and view all the answers

What is the correct way to document allergies to medications?

She had an anaphylactic reaction to penicillin. Signup and view all the answers

When dictated, how should 'the patient' be typed?

the patient. Signup and view all the answers

What punctuation should be used with lowercase abbreviations?

Do not punctuate Signup and view all the answers

Study Notes

Gaps in Audio

Gaps in the audio occur where dictation has been "scrubbed" for confidentiality reasons
Insert [Name], [Date], etc., at these points, as appropriate
[NAME] and [DATE] are also acceptable alternatives

Work Types

Types of reports that can be worked on include:
- Procedure Notes
- Discharge Summaries
- SOAP Notes
- Clinic Notes
- History and Physicals
- Radiology Notes
- Admission Notes
- Pathology Notes

Report Completion and Submission

Complete one report at a time before submitting and starting a new report
Any required self-graded reports in the queue must be graded before starting a new report to avoid repeat errors

Date Format

Convert all dictated dates to MM/DD/YYYY format, regardless of how they were dictated
If month and date are dictated but not year, insert YYYY
Correct dates not dictated in the correct format (e.g., "June of last year" becomes 06/DD/YYYY)
Totally scrubbed dates should be inserted as [Date] or [DATE]

Abbreviations and Symbols

Transcribe abbreviations as dictated, except in certain sections (Name of Procedure, Diagnosis/Diagnoses, Impression, Assessment)
Expand abbreviations in headings, except for diagnostic data (e.g., ALT, GGT, TSH, MRI) and Latin abbreviations (e.g., p.r.n., b.i.d.)
Metric units of measurement are not expanded when following a numeric value
Do not punctuate uppercase abbreviations (e.g., MD, COPD, IV)
Punctuate lowercase abbreviations (e.g., b.i.d., t.i.d., q.4)

Time and Dosage

Use a.m./p.m. for time and dosage, not AM/PM
Use a plus sign or minus sign only with a numeral
Write out "plus" or "minus" if the meaning is not clear

Units of Measurement

Use the correct abbreviation for gram or grams (g, not gm)
Do not write out metric units of measure if dictated with a number
Do not place a space between the numeric value and unit of measure when referring to liters of oxygen (e.g., 3L of oxygen)

Times

The word "times" can be written as "x" when dictated before a number
Use lowercase x for expressions of area and volume, as a multiplication symbol, and when it takes the place of the word "times"