Podcast
Questions and Answers
What is the correct format for a date dictated as "June of last year"?
What is the correct format for a date dictated as "June of last year"?
In which section of the report should abbreviations be expanded?
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?
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?
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?
What is the correct way to transcribe the dictation "[Name]" in the report?
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When should a new report be submitted?
When should a new report be submitted?
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What should be done with self-graded reports before starting a new report?
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?
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?
How should the abbreviation for grams be correctly written?
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Which of the following is the correct format for time notation?
Which of the following is the correct format for time notation?
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When representing liters of oxygen, which format is correct?
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?
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?
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?
What is the correct way to document allergies to medications?
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When dictated, how should 'the patient' be typed?
When dictated, how should 'the patient' be typed?
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What punctuation should be used with lowercase abbreviations?
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.
