Medical Report Writing Guidelines

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