Guest guest Posted October 16, 2001 Report Share Posted October 16, 2001 I got this a couple of weeks ago. It came as an attachment, but we all hate to open those, so I'm pasting it here. If anyone would like me to send the original attachment, please let me know. Hope this is helpful!! ---------------------------------------------------------------------------- -- SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS INTRODUCTION Since the latest AAMT Book of Style was published in 1995, AAMT has changed its preference in some areas. These changes have been documented in various volumes of the Journal of the American Association for Medical Transcription (JAAMT), and they have been included in the AAMT Book of Style - The Video. This document recaps most of the information covered by the AAMT Book of Style - The Video and is intended to be used as a supplement to the printed AAMT Book of Style. CONFIDENTIALITY Personal identifying information should not be typed within the text of a document. If it is dictated, you must edit it out to protect patient confidentiality. Generally, what will need to be changed is the patient's actual name to " the patient " or whatever makes sense. If it is dictated that the patient is " the CEO of Microsoft " or " the comptroller of ABC Company " or something similar that would specifically identify the patient, then that would have to be edited out also. This is a result of recent HIPAA legislation. Spacing After Periods and Colons: AAMT now prefers using one space rather than two spaces after periods and colons; however, since this is not something that all organizations in the industry agree with, you still have some discretion in choosing which style you prefer to use. However, you must be consistent within a document! By the way, never use more than 2 spaces after a period or a colon. Clipped Sentences: It is acceptable to transcribe clipped sentences (phrases) when dictated, as long as they make sense within the context of the document. Typing Abbreviations When Dictated: Type abbreviations when dictated, unless they are in an operative title or in the diagnosis, impression, or assessment. " x " meaning " for " and " x " meaning " times " : When the word " times " is used to indicate duration, the dictator is speaking in shortcuts and symbols, most likely reading from notes on a patient's chaff. " Times 2 days " actually means " for 2 days, " and AAMT suggests editing accordingly. Example: Dictated: The patient had vomiting times two days. 1 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Transcribe: The patient had vomiting for 2 days. When a client insists on the word " times " being transcribed, AAMT prefers it be typed as " The patient had vomited x2 days. " (Note the lack of spaces between the x and the numeral!) There are times when the word " times " actually means " times, " which should NOT be edited. The symbol and the numeral, written without a space, is the preferred expression. Example: Dictated: Blood cultures were negative times three. Transcribed: Blood cultures were negative x3. Using Numerals Rather Than Spelling Out Numbers (including single-digit numbers): Probably the biggest change AAMT has made is the preference for using numerals rather than spelling out numbers in medical reports (this includes the numbers 1-9). Numerals communicate more quickly and clearly. This also includes ordinal numbers, e.g., 1st, 2nd, 3rd, 4th, etc. [Please make a note in your AAMT Book of Style concerning this change. The numbers section begins on page 232 in the 1995 edition of the AAMT Book of Style.] Examples: The patient has 3 children. He was seen 2 weeks ago. She has been ill for 4 days. He took his last Tylenol 1 hour ago. The laceration was 1 inch long. The room had 8 chairs along the wall. The doctor removed 9 lymph nodes. She has 5 cats. He is to return in 2-3 days. It has been 6-7 years since he had a tetanus shot. The child is 10 years old. This 33-year-old male presents with. Also: The 5th specimen was contaminated. She was in her 7th month of pregnancy. The 4th cranial nerve was intact. He is to take the medication on the 1st day of the month. The 2nd metatarsal showed a fracture when x-rayed. The 4th through 5th ribs were tender to palpation. This is the 11th time he has presented to the emergency room in the past year. NOTE ON ORDINALS FROM THE AMERICAN MEDICAL ASSOCIATION MANUAL OF STYLE: 2 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Ninth Edition, copyright 1998, published by & Wilkins From page 514, #16.2.5: Ordinals generally are used to express order or rank rather than to emphasize quantity, and so ordinals first through ninth are to be spelled out. Exceptions are ordinals that are part of a series that includes an ordinal greater than ninth. Ordinals greater than ninth are expressed as numerals (10th, 11th, and so on), except at the beginning of a sentence, title, subtitle, or heading. Use the following suffixes: -st, -nd, -rd, -th. When to use " one " instead of " 1 " and " first " instead of " 1st " : In general, if the number is not a quantity, a measurement, an age, a lab value, or used in a series of items, you would NOT use a numeral. A good way to test this is to see if you can replace the number with another word. These exceptions mainly have to do with " one " or " first. " You would NOT use a numeral in instances such as the following: He is sure that one day he will walk again. [This is the same as saying " someday. " ] They complement one another. [This is the same as saying " each other. " ] His one complaint is the pain in his foot. [This is the same as saying " only. " ] The last one was 3 weeks ago. [This is the same as saying " the last time. " ] She has 3 children, but the only one I remember has red hair. [This is the same as saying " the only child. " ] She had an x-ray today and was advised to get another one in 6 months. [in this case, the word " one " could be replaced with the word " x-ray. " ] Also: At first he said he was not in pain, but then he said his foot hurt a little. Starting a Sentence with a Numeral: AAMT still follows the rule of NOT starting a sentence with a numeral; however, it is acceptable to start a sentence with a numeric year. Example: 1992 was the year her symptoms began. (Acceptable) Or you can recast the sentence so that it reads: " In 1992 her symptoms began " or " Her symptoms began in 1992 " ; however, you do not have to recast the sentence in this case. Otherwise, it is best to recast the sentence to avoid starting with a number, if it doesn't require any major editing. If you must start a sentence with a number, the number must still be spelled out (with the exception of the numeric year, as above). Example: Ten years ago she had muscle spasms in the lumbar area and was off work for 2 days. Or preferably recast the sentence to read: " She had muscle spasms in the lumbar area 10 years ago and was off work for 2 days. " 3 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS When the doctor starts out saying something like " 18-year-old female presents to the emergency room..., you must add something like " A " or " An " or 'The " or " This " to avoid staffing the sentence with a numeral. EXCEPTION: When typing a list of statistical data, such as vital signs or laboratory values, it is sometimes very difficult to avoid starting with a number. Example: It is acceptable to type something like " VITAL SIGNS: Temperature: 98.5. Pulse: 96. Respirations: 20. Blood pressure: 110/76. Weight: 134 pounds. Height: 63 inches. " Or " TIME SEEN: 0500. " Neighboring Numbers: You must spell out one of the numbers if two numbers appear side by side, because it would be difficult to read and communicate. If possible, use a numeral with the unit of measure (see examples below). EXCEPTION: If neither number can be readily expressed in words and the sentence cannot be easily recast, you should use a comma to separate adjacent unrelated numbers. Examples: The two 8-inch drains were functioning properly. There were five 4-0 nylon sutures placed. She had six 6-cm lacerations on her arm. Example of Exception: In March 1999, 938 patients were seen in the emergency room Arabic Numerals Versus Roman Numerals: Roman numerals are being used less and less. AAMT prefers Arabic numerals over Roman numerals, unless Roman numerals are the documented and well-established preference. The reason for this is compelling: as Tessier stated, an entire generation of people do not know how to read Roman numerals! If the most important part of medical transcription is conveying information, then reason enough for Arabic numerals is the fact that a caregiver might not know the difference between Roman numeral IV and VI. For cranial nerves, AAMT prefers using Arabic numerals, but the AMA still prefers Roman numerals. Therefore, you would transcribe " cranial nerves 2-12 " - NOT " cranial nerves II-XII. " However, this rule is not yet hard and fast. Rather, it is an indication of what the future will bring. If ordinals are dictated, it is preferred to transcribe " 1st cranial nerve " rather than " first cranial nerve. " Example: " The 1st cranial nerve is intact. " You would definitely not mix ordinal numbers and Roman numerals in the same sentence. And never transcribe " 1st cranial nerve " ! Example: 4 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS The 1st cranial nerve is intact, as well as cranial nerves 2-12. (Correct) The 1st cranial nerve is intact, as well as cranial nerves II-XII. (Incorrect) It is now correct to type " type 2 diabetes mellitus " rather than " type II diabetes mellitus. " The American Diabetic Association changed to this in 1998, and A.AMT has changed their rule accordingly. For grades, you must use Roman numerals or Arabic numerals when appropriate. You should consult a reference book to determine when to use Roman or Arabic numbers. Examples: Gleason grades 1-5 grade I through IV astrocytoma grade I through IV GVHD WHO grades I through IV Savary- II grade grade 1-6 heart murmur grades I and II oscillation grades 1-5 mobilization grades 1-3 signal intensity grade IV spondylolisthesis House-Brackman grades I-VI grades I-IV breast ptosis lymphedema grades II and III Ranges: AAMT continues to prefer numerals when typing a range. Please refer to the AAMT Book of Style, copyright 1995, for instructions on when to use a hyphen between the numerals and when to use the word " to " - do NOT use a colon between the limits of a range. Colons are used to express ratios, not ranges. Examples: I saw the patient 4-5 weeks ago. The cancer recurred 9-10 years later. There are 30-35 reports left to transcribe. He had 8-12 white blood cells, or He had 8 to 12 white blood cells. (Either way is acceptable.) But That piece of equipment cost $45 to $50 thousand. It varied from -25 to +48. Her weight fluctuates between 120 and 130 pounds. 5 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the £ & JVIT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Platelet counts have been 120,000 to 160,000. Blood pressure ranges: 100-120 over 70-90 or 100 to 120 over 70 to 80 but NOT 100-120/70-80 and NOT 100/20 to 120/80 Heart murmur ranges: [NOTE: Roman numerals are NOT acceptable.] A grade 2 to 3 over 6 murmur Or A grade 2-3 over 6 murmur Or A grade 2/6 to 3/6 murmur but NOT A grade 2-3/6 murmur and NOT A grade II-III/VI murmur. Units of Measure: English units of measure should be spelled out, but the value should be a numeral. Examples: 5 feet 5 inches [not 5'5 " and not 5 ft. 5 in. and DEFINITELYNOT 5 foot 5 inches! Never use punctuation between the feet and inches.] 60 inches [not 60 " and not 60 in.] l20pounds [not l2Olb.] 5 ounces [not 5 oz.] 60 miles per hour [not 60 mph and not 60 miles/br] 98 degrees [Do not make it " 98.0 " unless dictated as such.] Metric units of measure should be abbreviated when accompanied by a value. Examples: 10.5mm 3L 20 mcg/dL 0.5 cc [be sure to add the " zero " before the decimal point if not dictated.] 1 cm [Do not make it " 1.0 " unless dictated as such.] 6 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Fractions versus Decimals: Use fractions with English units of measure and decimals with metric units of measure, regardless of how it is dictated. Examples: 5-1/3 feet [not 5.33 feet] 4-1/2 inches [not 4.5 inches] 120-3/4 pounds [not 120.75 pounds] 3-1/4 ounces [not 3.25 ounces] 1.5cm [not 1-1/2 cm] 10.25 mm [not 10-1/4 cm] Mixed Fractions: Mixed fractions should always be transcribed as numerals. Examples: The child was 1-1/2 years old. The patient had been ill for 2-1/2 weeks. Superscripts and Subscripts: When a computer system is capable of making superscripts and subscripts (and if they transmit properly from one computer system to another), it is acceptable to use superscripts and subscripts. Otherwise, the number should be typed on the line or recast when possible Examples: 75,000/mm3 [Acceptable per AAMT] or 75,000/mm3 [Acceptable] or 75,000 per cu mm [Acceptable] or 75,000 per mm cu [Acceptable] Also: Dictated: Ten to the sixth. Transcribe: 10 to the 6th. Or 10 to the 6th power. Plus and Minus Signs: Blood Types: 7 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Always type as " B positive " or " A negative. " Do not type as " B- " or as " A+ " [The rationale is that the minus sign or plus sign could be easily misread on the page.] Lab Values: Urine showed 4+ sugar. (Correct) Urine showed ++++ sugar. (Incorrect) Commas/Periods: It is acceptable to use a comma anywhere as long as it follows standard punctuation rules, but a comma is only " required " if it is necessary to clari & the meaning of the sentence. The trend is toward using as few commas as possible and still communicating clearly Commas/Periods with Titles: The use of periods within abbreviated titles is decreasing (e.g., " Jr " or " PhD " and sometimes " MD " ). " CMI " has never had periods. Example: Will Jr (Preferred without a comma before " Jr " and without a period after " Jr " ) , Will, Jr (Preferred without a period) Commas Within and/or Surrounding Numbers: It is not necessary to use a comma with a 4-digit number, but for 5 or more digits you do need a comma. Examples: White count is 5300. White count is 10,000. Platelet count is 100,000. White count 5300 with a shift to the left. (Acceptable) White count 5300, with a shift to the left. (Acceptable) White count, 5300, with a shift to the left (Incorrect) A 3-year 2-month-old boy presented with his mother. (Correct) A 3-year, 2-month-old boy presented with his mother. (Incorrect) The patient was 5 feet 4 inches tall. (Correct) The patient was 5 feet, 4 inches tall. (Incorrect) 8 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS The patient was 5 foot 4 inches tall. (Incorrect) The patient was 5 '4 " tall. (Incorrect) Quotation Marks Quotation marks are to be placed at the beginning and end of a direct quotation. If an uninterrupted quotation extends beyond one paragraph, place opening quotation marks at the beginning of each paragraph, but place an ending quotation mark only at the end of the final quoted paragraph. Capitalization Within a Quote: DO begin a complete quotation with a capital letter if it is not grammatically joined to what precedes it. Examples: The path report reads, " Specimen is consistent with microadenoma. " The patient says, " I feel awful. " DO NOT use a capital letter to begin incomplete quotations or those joined grammatically to what precedes them: Examples: She says that she has " bad blood. " The patient says that she feels " awful. " Commas Before a Quote: Follow " she said " or similar attributions with a comma when they precede a complete quote. Examples: She said, " My knee hurts. " The doctor said, " I will release you tomorrow morning if there are no complications. " Commas Following a Quote: Always place the comma following a quotation INSIDE the closing quotation marks. Example: The patient stated, " The itching is driving me crazy, " and she scratched her arms throughout the meeting. Periods Following a Quote: Always place the period INSIDE the quotation marks. 9 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Example: The consultant's report reads, " The patient is a 21-year-old male who was referred to me by Dr. . " Question Mark Following a Quote: The placement of a question mark in relationship to ending quotation marks depends on the meaning. Place the question mark INSIDE the ending quotation marks if the material being quoted is in the form of a question. Example: The patient asked, " Must I return for followup that soon? " [Note that no period follows the ending quotation marks; never combine a question mark with a period.] Place the question mark OUTSIDE the ending quotation marks if the entire sentence is a question. Example: Is it acceptable to say " I don't know " ? Semicolons Following a Quote: Always place the semicolon OUTSIDE the quotation marks. Example: The patient clearly stated " no allergies " ; however, his medical record states he is allergic to penicillin. The Apostrophe:. Contractions: Always spell out contractions in medical documents, unless used in a direct quote surrounded by quotation marks. Example: Dictated: The patient said he didn't feel very well. Transcribed: The patient said he did not feel very well. But Dictated: The patient said I don't feel very well. Transcribed: The patient said, " I don't feel very well. " 10 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Possessives: Examples: The miscarriage happened after 35 weeks' pregnancy. or The miscarriage happened after 35 weeks of pregnancy. The baby was born at 32 weeks' gestation. or The baby was born at 32 weeks of gestation. TIP: If inserting the word " of' makes sense, then the word is possessive and requires an apostrophe. However, the following are NOT possessive and do not require an apostrophe: It was a 35-week pregnancy. The woman was 35 weeks pregnant. " Its " Versus " It's " The word " it's " with an apostrophe is a contraction. The only time you should use it is if you can interchange it with " it is. " Example: It's time to go. Contrary to the general rule for possessives, the word " its " (without the apostrophe) is the possessive form. Example: The patient has a large burn; its dimensions are 3 x 4 x 5 inches. Extended Abbreviations That Contain Contractions When dictated (unless in a diagnosis, assessment, or impression), it is acceptable to use extended abbreviations that contain contractions. Examples: The patient OD'd on heroin. The abscess was I & D'd. 11 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Eponyms: It is preferred that the possessive form not be used for eponyms; however, it is okay to type with an apostrophe if dictated without the associated noun following the name of the condition. Examples: The patient has Alzheimer's. Or The patient has Alzheimer disease. The patient was diagnosed with Lyme's. Or The patient was diagnosed with Lyme disease. Homans' was positive. Or Homans sign was positive. (Both of these ways are acceptable.) But NOT: Homan's sign was positive. (Rationale: the guy's name was Dr Homans!] Latin Abbreviations: Latin terms should be abbreviations (with periods) when dictated; however, Latin abbreviations should not be mixed with English terms. Example: Dictated: q 6 hours Transcribed: q.6h. or every 6 hours but not " q. 6 hours " - Per AAMT, since there is apparently no Latin abbreviation for minute or month or year, you must spell out the phrase. Example: Dictated: q 5 minutes Transcribed: every 5 minutes Not q.5m. And not q.5 minutes If a client insists that " q. " be typed, then you should transcribe it as " q. 5 minutes " - with a space between " q. " and the number. Followup versus Follow-up versus Follow up: " Followup " is one word when used as a noun or an adjective. Examples: Followup will be in 3 weeks with Dr. . The patient is to come for a followup visit in 6 months. 12 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS " Follow-up " with a hyphen is acceptable (but not necessary) when used as an adjective; however, it is NOT acceptable to hyphenate when used as a noun. Examples: The patient is to come for a follow-up visit in 6 months. (Acceptable) The patient is to come for a followup visit in 6 months. (Preferred) " Follow up " (two words) is correct when used as a verb form. Examples: The patient was instructed to follow up in 2 weeks. The patient will follow up as needed. [TIP: To check yourself with the above terms, try saying the phrase with an " s " on the word " follow " ; e.g., " She follows up. " It doesn't make sense to say " She comes for a follows up visit " - it must be " She comes for a followup visit. " It doesn't make sense to say " The patient's follows up will be in 3 weeks " - it must be " The patient's followup will be in 3 weeks. " However, it does make sense to say " She follows up in 3 weeks " - in this case two words would be correct, because it is used as a verb.] You can use the above tip for similar terms, such as " workup versus work up " and " makeup versus make up, " etc. Plurals Some words are considered plural all of the time and, when used as the subject of a sentence, require a plural verb. There is no singular form. Examples: The adnexa were nontender. The left adnexa were painful to palpation. [NOTE: This is correct even though referring to only one side. The word adnexa is Latin for accessory parts and as such, it is ALWAYS plural.] The scissors were missing. but The pair of scissors was missing. [NOTE: Use a singular verb here because " the pair " is the subject.] Obstetrics Terminology: The term " aborta " is NOT correct. The correct term is " abortus " whether referring to singular or plural. 13 SUPPLEMENT TO THE AAMT BOOK OF STYLE (Taken from the AAMT Book of Style - The Video) PLUS COMMONLY MADE ERRORS Example: The patient is gravida 3, para 1, abortus 2 (Correct) The patient is gravida 3, para 1, aborta 2 (Incorrect) Or G3, P1, A2 Or G3, P1, Ab2 (Correct) Separate " TPAL " (which stands for term pregnancies, premature births, abortions, live births) numbers by hyphens. Example: " Obstetrics history: 4-2-2-4 " It is okay to combine GPA terminology with TPAL terminology. Example: The patient is gravida 4, para 1-0-2-1 (correct) Quote Link to comment Share on other sites More sharing options...
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