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GENERAL STATEMENT ON FORMATTING AND STYLE:
Formatting and style can be summed up in two words: BE CONSISTENT.
The AAMT Book of Style is the best source for answers.
The rule of thumb is: If your client asks for a specific formatting/style, you follow their rules, even if they may contradict the AAMT standard. If your client is silent on a style subject, best to go with the AAMT style.
So the items which follow are based on AAMT style standards, but you would modify to suit your particular client's rules.
SUBJECTS COVERED BELOW:
· Abbreviations and expansion of
· Abbreviations and dose designations, dangerous forms of
· Clock referents for times and anatomic positions
· Blanks and difficult dictation
· Contractions
· Diagnosis/diagnoses
· Dosage style (punctuation, mixing Latin and English, plus comments on "q")
· Eponyms and possessive forms
· Impression, assessment, diagnoses statements and abbreviations
· Macros, autokeys, normals templates
· Numbers: Arabic numbers and Roman numerals
· Repeated items in reports
· Semicolons
· Subcutaneous injection abbreviation
· Verb tense
ABBREVIATIONS AND EXPANSION OF:
Watch out for times when a dictator will use an abbreviation and add another word with it and then if you expand the abbreviation, a word is duplicated.
A good example is, dictator says "Patient had a LEEP procedure." When you expand LEEP, and if you keep the sentence as is, it will now read "Patient had loop electrosurgical excision procedure procedure" (with the P in LEEP standing for procedure). You would remove the second instance of "procedure" in that sentence. Even if the term is not expanded, you would remove the second "procedure" so the sentence reads "The patient had a LEEP." (not "a LEEP procedure"). Another example: "Patient has history of HSV virus." With HSV standing for herpes simplex virus, if expanded you would have virus in the sentence twice. The sentence should just read "The patient has a history of HSV (not expanded form) or "The patient has a history of herpes simplex virus." (expanded form)
ABBREVIATIONS AND DOSE DESIGNATIONS, DANGEROUS FORMS OF:
The Institute for Safe Medication Practices (ISMP) and the United States Pharmacopeia have developed a list of abbreviations and dose designations that are dangerous to patient safety. AAMT Book of Style has printed a list of these dangerous terms and their preferred expression. This list has also been adopted by the JCAHO.
This is not the entire list, but some common ones are:
IU = change to "unit"
Medications with capital letter designations (examples HCTZ, TAC,AZT, MgS04): Can be confused as other terms, so use complete spelling for drug names.
per os = change to "PO," "by mouth" or "orally"
qd, q.d., QD= change to "daily" or "every day"
q.o.d., qod, QOD = change to "every other day"
qhs = change to "nightly"
subq = change to "subcut" or "subcutaneous"
TIW, tiw (with the intended meaning of "three times a week") = don't use this term, spell out words
U, u = change to "unit"
/ (slashmark) to indicate "per" (example 25 cc/ml) = change to"per" and don't use / to separate doses
zero after decimal point (example 2.0 mg) = do not use terminal zeros for whole numbers
CLOCK REFERENTS FOR TIME AND ANATOMIC POSITIONS:
The AAMT Book of Style standard is:
1. Clock times:
a) If military time is dictated, use 0001 to 2400 (four numerals with no colons, add zeroes if necessary to make four numerals). Do not add AM or a.m., PM or p.m. If the word "hours" is not dictated, it may be added for clarity, but this is not absolutely necessary.
b) If not using military time, use numerals, separated by a colon, to express hours and minutes (example 8:15 a.m.), EXCEPT FOR MIDNIGHT AND NOON. For on-the-hour expressions it is preferable not to add the colon and 00.
Examples: 8 a.m. or 8 o'clock in the morning. BUT NOT: 8:00 a.m. NOT: 8:00 o'clock. NOT: 8 a.m. o'clock. NOT: 8 o'clock a.m. NOT: eight o'clock.
Examples: Type "noon" NOT 12 o'clock; "midnight" NOT 12 o'clock.
2. Clock referents for anatomic positions: 1 o'clock to 12 o'clock.
When an anatomic position is described in terms of clock face orientation as seen by the viewer, use o'clock unless the position is subdivided.
You will usually hear anatomic positions given as whole hour numbers (example: 3 o'clock position). It's rare to get an x:30 subdivision, but if you do it should be typed thus:
Dictated as: "The cyst was found at the 2:30 o'clock position."
Type as: "The cyst was found at the 2:30 position."
REMEMBER, these are the general AAMT rules, and there may be clients who want clock referents a specific way, and not necessarily as above, so follow your client's rules if they differ from AAMT style.
BLANKS AND DIFFICULT DICTATION:
My advice: If you come across a dictator who speaks rapidly, avoid the temptation to just turn down the speed and listen to the whole report slower. Try to do the report all the way through at regular speed and just put in blanks as you go for the parts you couldn't get. Then when you get to the end, go back and slow down the report and try to fill in the blanks.
The reason for this is partly psychological. If you are listening the first time at the slowest speed and you have to leave a blank, you have nowhere to go but faster and you know you probably won't figure it out. If you do it at regular speed and leave a blank you can tell yourself that you can probably figure it out when you go back and slow it down.
Now I'm not saying that you can't slow something down right at the time you are stumped instead of waiting to the end, but that seems to take longer, and I find it quicker in the long run to just keep going and put in a blanks (use something like _______ so it is very obvious where the blank is) and go back afterwards to pick up the blanks. Also if you keep going sometimes they will say it again and you will get it the next time and be able to go back and fill in the blank without slowing it down at all.
CONTRACTIONS:
The rule is to NOT use contractions even if dictated unless they are part of a direct quote.
DIAGNOSIS versus DIAGNOSES:
Just a reminder that if there is more than one diagnosis in a list, even if the dictator says "diagnosis" you should change it to the plural version "diagnoses."
DOSE DESIGNATIONS AND ABBREVIATIONS, DANGEROUS FORMS OF:
See ABBREVIATIONS AND DOSE DESIGNATIONS above.
DOSAGE STYLE (PUNCTUATION, MIXING LATIN AND ENGLISH, PLUS COMMENTS ON "q"):
The use of "q" in Latin expressions of time is often misused and mixes Latin and English. Example: q week, q six months, q Friday. The q in phrases like these should be changed to "every" as there are no such terms and also because "q" in dosages or expressions of time should never stand alone to avoid misreading of a term.
The AAMT Book of Style prefers lowercase abbreviations with periods for Latin abbreviations that are related to doses and dosages (i.e., b.i.d.)
Do not use abbreviations found on the "Dangerous Abbreviations" list (See ABBREVIATIONS AND DOSAGE DESIGNATIONS, DANGEROUS FORMS OF above).
Avoid using all capitals because they emphasize the abbreviation rather than the drug name.
Avoid lowercase abbreviations without periods because some may be misread as words.
The Institute for Safe Medication Practices also recommends adding a space after the number to be more easily and clearly read in this type of dosage instruction: q.4 h. NOT q.4h.
NOTE: Remember some clients may request that you use the Latin abbreviations WITHOUT PERIODS, CAPITALIZED FORMS, etc. Always follow your client's instructions.
EPONYMS AND POSSESSIVE FORMS:
An eponym is a name of a drug, disease, anatomic structure, operation, etc. derived from the name of a person or place. AAMT style is to NOT use the possessive form even if it sounds odd without the 's, so we would say Ringer lactate, Parkinson disease, Graves disease for example. (BTW, Graves is a plural name. If we used the 's form this term would be Graves' disease.)
IMPRESSION, ASSESSMENT, DIAGNOSES STATEMENTS & ABBREVIATIONS:
Medicare and HIPAA (Health Insurance Portability and Accountability Act of 1996) have mandated that any abbreviations other than lab and x-ray terms (and other exceptions per each individual client like immunization names [MMR, IPV, DTaP], and certain terms like HIV and AIDS) must be expanded in the diagnosis or assessment section so that there is no way to misinterpret a diagnosis of a patient.
You may have a client who asks that you use abbreviations even in the diagnosis/assessment section. However, to meet Medicare/HIPAA standards, a client may require you to expand an abbreviation the first time it is used and follow with the abbreviation in parenthesis.
Example: Dictated as "CVA."
Typed as "Cerebrovascular accident (CVA)."
Then if that same abbreviation is dictated again in the diagnosis/assessment section, you may use the abbreviation.
MACROS, AUTOKEYS AND NORMALS TEMPLATES:
Macros or autokey programs can be purchased separately and used with your dictation. Or often your employer will have macros and autokeys built into their program for you to use. These could be locked and not adaptable by you, or the program could allow you, the user, to modify them to suit your tastes.
One of my previous employers used a macro program that I could adapt, so I went through the supplied list and kept the ones I wanted, deleted some, and then I continued to add as needed. A macro can expand into just one word or a whole phrase or sentence, but usually has a limit to the number of characters in each macro, so if it is a long phrase you might have to split it into more than one macro, or turn it into a normal (see next paragraph). But if you are using "Microsoft Word's autocorrect options feature (which is what I'm using with my present employer) the character length seems unlimited.
Your program might also have what are called normals. These can be templates that the dictators want (a format they like or terminology they use over and over) and is supplied to you by the client, or you can create our own normals. This is the best way to do large paragraphs that are too long for a macro. They work great for saving whole reports of a particularly difficult dictator which can be referred to when you are stuck on what is being said.
NUMBERS: ARABIC NUMBERS AND ROMAN NUMERALS:
Per AAMT Book of Style: Numerals, or figures, stand out from the surrounding text and serve a functional purpose in medical reports, where they should be used almost exclusively as opposed to spelled-out numbers.
In nonmedical-report writing, the style is for numbers under 10 to be spelled out and over 10 to use numerals, but in medical reports it is preferred to use numerals throughout.
Examples of use of numerals in medical reports:
She was seen by me within 1 hour of the accident. He tried 3 different drugs for his headaches.
Exception: When two numbers are consecutive, spell out one of them to avoid confusion. Example: Patient instructed to drink 8 8-oz glasses of water per day. Change to: eight 8-oz glasses. Example: We used 2 8-inch drains. Change to: two 8-inch drains.
You can spell out or use numerals for common fractions. Example: He smokes a pack and a half of cigarettes per day. OR: He smokes 1-1/2 packs of cigarettes per day.
Also AAMTstandards (and JCAHO standards) are to leave off the 0 after the point for a whole number, even if dictated, as this could be read incorrectly. Dictated: Creatinine was 1 point 0. Typed: Creatinine was 1.
Examples of Arabic numbers and Roman numerals:
Classes: I-IV (like New York Heart Classifications).
Diabetes mellitus types: 1 and 2 per current ADA guidelines...(not Roman numerals I and II anymore)
Genotypes: 1a, 1b, etc.
Gleason score: 1 to 10. May be seen as whole number or fraction. "Gleason score 6." or "Gleason score 6/10." May also see as the components which make up the score, i.e., "Gleason score is 3 + 3 = 6/10."
Grades: 1-4 (i.e., cancer)
Heart murmurs: 1/6, 2/6, 3/6, etc. AAMT style has changed to using Arabic numerals for murmurs even if dictated as Roman numerals. Also if a range is given, example "Systolic murmur one to two out of six" you DO NOT type "1-2/6 or 1 to 2/6." You should type "1/6 to 2/6."
Model and serial numbers: Use Arabic numbers. Example: model C453, model #C453, serial #A13045.
Pain scale: 0 to 10, with usually a fraction stated. Dictated as "Pain scale one to two out of ten" would be typed 1-2/10 (notice this is in direct contrast to heart murmurs above). Dictated as "Pain scale one over ten" would be 1/10. Dictated as "Pain scale one of ten" would still be 1/10.
Powers of 10: (exponentials). Example: "10.2 times 10 to the 6th." This is if the client's program doesn't have the capability to print out the formula in strict algebraic format (and most don't have that capability).
Reflexes: Range goes from absent to 4+ (absent, 1, 1+, 2, 2+, 3, 3+, 4, 4+). Note: If a range is dictated be careful how you type it. Dictated: "Reflexes 1 to 2+." Type exactly as stated, as you can see that "Reflexes 1+ to 2+" is not the same as "Reflexes 1 to 2+."
Skin types: I, II.
Stages: I-IV (cancer, Tanner, FIGO)
Strength: 0 to 5+.
Subscript, superscript numbers: Many client programs don't have the capability to print out these numbers correctly, so we usually just type in line with term, or sometimes hyphenate, i.e. H2O, beta-2 carotene. If your program or the client's program has the capability to subscript or superscript, you can use it.
REPEATED ITEMS IN REPORTS:
If the same thing is repeated in the same section (like twice in History of Present Illness or twice in Review of Systems) you probably would delete the second instance, but be careful that it is actually a repeated item.
BUT if it is listed in two completely different areas (like in the History of Present Illness and then again in the Review of Systems) then it wouldn't be deleted. Also some dictators develop their own style, like basically doing a complete SOAP format for each identified problem, and then they repeat things like "no fever and chills" if it applies to more than one problem. In that case you would, of course, leave in any repeats because they are linking these symptoms to a particular named problem.
SEMICOLONS (EXAMPLE: HOWEVER):
If you just get the hang of "however" you will be most of the way there with use of the semicolon, as that probably is the most used term that needs it.
However, a trick with "however" is that if you really have a hard time figuring out where to put commas or semicolons, you can just make two short sentences with the second sentence starting with "however." It might not be acceptable in regular writing, but it is okay in medical reports.
Examples: It is rainy today. However, the baseball game is still on.
This could be done as two sentences OR if you connect the phrases, it would be:
It is rainy today; however, the baseball game is still on. "However" connects two complete sentences/clauses with subjects and verbs and that's why you need a semicolon.
I like to think of it like this: Read the parts that are connected by "however" out loud and see if it sounds like you would take a breath just before "however," (equivalent to pause), and then you put emphasis on the word "however." If so, then that requires semicolon before (semicolon=breath) and comma after.
But there are times when "however" connects phrases and it just needs two commas, but those should become obvious because they usually have a second connector with the clauses.
Again, read the parts aloud. If you see that you don't put emphasis on the word "however" and it seems to flow with the first clause, and your voice actually drops on the word, then it doesn't need a comma + semicolon---just two commas.
Here's an example: They said the game would be called if there was even a drop of rain. It is rainy today, however, and the baseball game is still on (notice "and" is the connector for the two clauses).
SUBCUTANEOUS INJECTION ABBREVIATION:
AAMT Book of Style has listed the abbreviation "subq" as a one of their dangerous abbreviations. I f subcutaneous is dictated as "sub q," it should be typed as "subcut" or "subcutaneous" to avoid misreading the term.
VERB TENSE:
There is no set rule on using past or present tense. It has just become a rule of thumb to use present tense in the physical exam section. Anywhere else in the report can be past or present, although I prefer to use present tense in operations or procedures, but most of the dictators use more past tense than present in those areas, so I will often look through the paragraph after I'm done and see if he used past the most or present the most. Then I change to the one he used the most in that paragraph (in other words, try to change the least you have to).
Just because you change to one tense in one paragraph or section doesn't mean you have to stay in the same tense then throughout the whole report. You only need to be consistent with your tense within a paragraph.
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