Questions and Answers
What is the correct format for a date dictated as "June of last year"?
In which section of the report should abbreviations be expanded?
What is the correct way to transcribe the abbreviation "C-section" in the "Operative Procedure" section?
Which of the following is an example of a dangerous abbreviation that should be corrected?
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What is the correct way to transcribe the dictation "[Name]" in the report?
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When should a new report be submitted?
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What should be done with self-graded reports before starting a new report?
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Which of these is NOT a type of work that needs to be transcribed?
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How should the abbreviation for grams be correctly written?
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Which of the following is the correct format for time notation?
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When representing liters of oxygen, which format is correct?
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How should the term 'plus' be represented when not clear in meaning?
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What is the correct way to represent the word 'times' when dictating before a number?
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What is the correct way to document allergies to medications?
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When dictated, how should 'the patient' be typed?
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What punctuation should be used with lowercase abbreviations?
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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"
Allergies
- Capitalize the name of the medication/substance the person is allergic to, not the entire sentence
Formatting
- Type "the patient" when "patient" is dictated
- Format is left justified, with no bold, centering, underlining, or auto formatting
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Description
This quiz covers the formatting and editing guidelines for medical reports, including handling confidential information and completing various types of notes.