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Florida Hospital TampaFlorida Hospital CarrollwoodFlorida Hospital at Connerton
Helen EllisZephyrhills
02/01/2012
The eScription Style GuideEditScript-MT
Customer (AHS) Defined Style Guide
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EDITING/TRANSCRIPTION STANDARDS
WORD/PHRASE CORRECT USAGE EXAMPLE
A, AN Use a before a consonant
Use a before a sounded h
Use a before a long u
Use an before a vowel
Use an before an unsounded h
a patient
a hemorrhoid
a unit
an indication
an hour
ABBREVIATIONS/ACRONYMS Use approved abbreviations as dictated unless
in the diagnosis section, procedure
diagnosis/name sections or operative
diagnosis/name sections.
Laboratory an !a"no#t!$ !%a"!n" t&#t# DO
NOT need to be expanded, even in above
sections.
!" should be expanded to lobal !ssessment
of "unctioning in the diagnosis section of all
ps#ch reports.
There is no s#novitis of the $%&s, &'&s or D'&s. There is some
s#novial thic(ening of the left )rd D'&.
D'!NO*'*
*#novitis of the left )rd distal interphalangeal +oint.
&O%-DU-
Total abdominal h#sterectom#.
T! dictated, but expanded as above in this section0
'$&-**'ON
$' shows intracranial hemorrhage.
!'* 2
lobal !ssessment of "unctioning3 45.
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!bbreviations are acceptable for units of
measure when used with a number0, dosages,
diagnostic tests and laborator# wor( for
exceptions, please see below0.
The abbreviation --NT can be used in the
ph#sical examination.
There are two abbreviations for hemoglobin
7 and gb0. 8e will be using HGB. *o,
hemoglobin A1c can be abbreviated HGB A1c.
Please Note: 8hen t#ping hemoglobin A1c,
please ma(e sure that #ou are t#ping a 1 and not
a l .
!lthough ph#sicians dictate sed rate, the actual
abbreviation is -* er#throc#te sedimentationrate0 and not sed. 'f the ph#sician dictates sed
rate, t#pe sedimentation rate. 'f the ph#sician
dictates ESR, use the abbreviation.
Do not abbreviate medications.
Do not use abbreviations when referring to the
e#es3 OD, OS, OU
9atin:based abbreviations3 !lwa#s place
periods between each letter for fre;uenc# of
medications.
Un!t# o' M&a#(r&%&nt) cm, mm, m-;, (g, mg, m9, mcg
Do#a"&#) b.i.d., t.i.d., p.r.n., p.o., n.p.o.
T&#t#) $', %T, -$/N%2, --, -<, !&!, %7%, 7N&.
--NT3 -#es are clear. -ars are clear.
left e#e, right e#e, both e#es
'N%O-%T %O-%T
npo n.p.o.
po p.o. prn p.r.n.
;am ;.a.m.
;pm ;.p.m.;id ;.i.d.
tid t.i.d.;4h ;.4h
;=h ;.=h
)
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&lurali>e acron#ms b# adding ?s?
&9-!*- *-- T- O""'%'!9 @DO NOT
U*-@ 9'*T !T T- -ND O" T'*
DO%U$-NT.
DTs, !D9s, &2%s, 87%s.
ABDUCTION/ADDUCTION 'f the ph#sician dictates ab:duction, t#pe
abduction.
'f the ph#sician dictates ad:duction, t#pe
adduction.
abduction
adduction
*ABLE AND +IBLE There is no shortcut in determining whether a
word ends in able or !ible. %onsult adictionar#.
AGE 8hen a ph#sician dictates a patientAs age at the
beginning of a sentence, do not add a or an.
&ut the word the at the beginning of the
sentence.
The patient is a B:#ear:old bo# who was hit b# a car.
The )C:#ear:old male presents with a histor# of tuberculosis.
A-A Use lowercase letters with periods . The patientAs name is $ar# *mith a"#"a" $ar# Thornheart.
A LOT, ALOT AND ALLOT The phrase a lot means to a considerable
;uantit# or extentE and is al$a%s written as two
words. DO NO& SPE'' &H(S PHRASE AS
ONE )ORD. A'O& (S NO& A )ORD"
Allot means to distribute or assign.
Than(s a lot .
Fou will have to allot a portion of next #earAs budget to bu# a new
computer.
ALLERGIES %apitali>e all drug allergies. NO <NO8N DU !99-'-*.
&-N'%'99'N, -FTO$F%'N, 9!T-.
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AMPERSAND .0 Do not use GHA. 't does not cross the interface
to %erner correctl#.
Use GandA instead.
ASSESSMENT AND PLAN *hould read @D'!NO*T'% '$&-**'ON.@ D'!NO*T'% '$&-**'ON%hronic obstructive pulmonar# disease.
AUDIO !9T I * will @un>ip@ audio silences. *#mbol
on toolbar will have a red line when un>ipped,
so #ou can hear silent parts/missed parts of
dictation.
BLAN-S Two ;uestion mar(s and five underscores.
Time stamp on transcribed documents.
Time stamp not necessar# on edited documents.
JJKKKKK
BREA-S/LUNCHES 1. @&ause@ function for brea(s L:15 minutes0.
6. *ign:out for lunch.
Do not use !9TI*'"TIU for lunch as it (eeps
documents in #our ;ueue.
The s#stem trac(s time that #ou are signed on, so using these
functions more accuratel# represents #our production time.
BUSINESS ENTITIES 2erif# correct business entit#. 'f not correct,
please change.
!9TI- and !9TI7 for business entit#.
CAPITALI1ATION %apitali>e ma+or/section headings.
Do not capitali>e department names, unless
meaning is ambiguous.
!lwa#s capitali>e3
!$!3 !!'N*T $-D'%!9 !D2'%-.
DN'3 DO NOT 'NTU7!T-.
'*TOF O" &-*-NT '99N-**
&!*T $-D'%!9 '*TOF
The patient was induced b# !nesthesia.
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DN3 DO NOT -*U*%'T!T-.
%OD- 79U-, -D. !99 %OD-*0
DU!79- &O8- O" !TTON-F
%apitali>e allerg# section.
Do not capitali>e diagnoses.
NO <NO8N DU !99-'-*.&-N'%'99'N !ND -FTO$F%'N.
'2 DF-.
D'!NO*-*
1. %holelithiasis.
6. #pertension.
). !sthma.
CONTRACTIONS Do not use contractions unless #ou are
specificall# ;uoting an individual.
The patient did not have his insurance card.
*he stated, ' didnAt get #our message until 15 p.m.E
DASHES AND SLASHES Do not use in headings.
Do not use in ranges. Use the word @to@
instead.
Use onl# when necessar# in bod# of report.
The patient will return in ) to 4 wee(s.
DATES D!T-* O" *-2'%-3
'*TOF !ND &F*'%!93 Do not t#pe
date, unless dictated.
D'*%!- *U$$!F3 !dmission and
discharge dates.
!99 OT- 8O< TF&-*3 'nclude date of
service as date dictated, unless otherwise
indicated b# dictator.
Use virgule t#pe M:digit date. $$/DD/FFFF
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8hen onl# month and #ear given, please
promote clarit#.
$$/FFFF
DEGREES "lexion to 45 degrees 8rite out degrees. Do not use the s#mbol.
DIAGNOSIS/DIAGNOSES 'f there is more than one diagnosis, the heading
is D(AGNOSES"
D'!NO*'*
!ppendicitis.
D'!NO*-*
1. !ppendicitis.
6. %holelithiasis.
DISCHARGE DIAGNOSIS *hould read @"'N!9 D'!NO*'*.@ "'N!9 D'!NO*'*
Diverticulosis.
"'N!9 D'!NO*-*1. Diverticulosis.
6. #pertension.
DOCTOR &ut period after @Dr.@ Dr. ones.
EXAMINATION/EXAM T#pe as dictated unless in a heading &F*'%!9 -!$'N!T'ON
is exam was negative.
2OLLOW*UP, 2OLLOWUP AND
2OLLOW UP
'f used an ad+ective or noun, t#pe followup or
follow:up.
'f used as a verb, t#pe follow up 6 words0.
The patient will have a followup chest x:ra#.
"ollow:up should be in = wee(s.
The patient will follow up in ) wee(s.
2RACTIONS T#pe as fractions Do not write them out, unless
at the beginning of a sentence.
No superscript.
There is edema about 6/) the wa# up on the calf.
Two:thirds of her calf is swollen.
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2RE3UENCY @x@ abutted next to the number. The patient was alert and oriented x).
GRADES/STAGES/TYPES !!7'% NU$7- D-NOT!T'ON1. rades of conditions and diseases.
6. %ranial nerves.
). T#pes of conditions and diseases.
O$!N NU$7- D-NOT!T'ON
1. *tages of conditions and diseases.
6. *alter:arris fracture.
). &s#chiatric diagnoses D*$0.
rade 6/= s#stolic murmur.
%'N grade 1, 6, ), or %'N 1, 6, ) this is a grade, not stage/t#pe0
%ranial nerves 6:16.
Diabetes mellitus t#pe 6.
*tage '' decubitus ulcer.
*tage '' cancer.
*alter:arris t#pe '.
!'* ', !'* ''.
HEADINGS AND SUBHEADINGS !ll ma+or headings are capitali>ed, no colon,
with text on next line single space underheading at left margin0.
'f a heading is not dictated but understood,
insert the appropriate heading.
!ll headings and subheadings are left:margin
+ustified. *ubheadings are to be capitali>edwith a colon followed b# two spaces, and then
text.
'*TOF O" &-*-NT '99N-**
The patient is a BL:#ear:old male.
&F*'%!9 -!$'N!T'ON
-N-!93 e is alert and oriented x).
'*TOF O" &-*-NT '99N-**
The patient is a =L:#ear:old male who presented with chest pain
and d#spnea. heading not dictated, but understood due to nature
of this text0.
&F*'%!9 -!$'N!T'ON
--NT3 Nose and throat are clear.*<'N3 8arm and dr#.
9UN*3 %lear to auscultation.
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No repetition of text in relative heading.
TYPE VERBATIM HEADINGS .E4$&5t!on)
Do6b&y r&7(!r&# $&rta!n 8&a!n"# !n HP,
Con#(6t# an D!#$8ar"& S(%%ar!&# + S&&
9Wor: Ty5&#;0
REMOVE ALL UNUSED HEADINGS
'N%O-%T3
&!*T $-D'%!9 '*TOF
&ast medical histor# is positive for asthma.
%O-%T3
&!*T $-D'%!9 '*TOF
&ositive for asthma.
HEIGHT, INCHES AND POUNDS Do not use s#mbols for feet and inches.
"ractions are separated b# a h#phen.
*pell out the word *o+nds.
The patient was = feet 4 inches.
The patient is L feet 4:1/6 inches.
The patient weighed 665 pounds.
HYPHENATION 9imited h#phenation, onl# when necessar# for
h#phenated compounds.
!lwa#s h#phenate patient?s age.
Do not use h#phen for ranges. Use the word
@to@ instead.
"inger:to:nose test.
8ell:developed, well:nourished female.
igh:power field.
This is a 46:#ear:old male . . .
The patient is a 6:1/6:month:old infant with . . .
The patient will return in ) to 4 months.
LISTS Denote lists with number, period, two spaces,
and then text.
1. #pertension.
6. %hronic obstructive pulmonar# disease.
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MEASUREMENTS Use numbers for fractions in dimensions.
!lwa#s put a 5 in front of a fraction that begins
with a decimal.
Use abbreviation for associated measurement
1.L cm
5.L cm
$-!*U-$-NT !77-2'!T'ON
%entimeters cm
<ilograms (g
$icrograms mcg
$illie;uivalents m-;
$illigrams mg
$illiliters m9
$illimeters of mercur# mmg
MEDICATIONS T#pe in list format.
'f dictated in paragraphed format, still create a
list.
$edications should alwa#s contain the
appropriate unit of measure if dosage is
dictated. 'f the ph#sician does not dictate the
unit of measure, #ou must loo( it up to see how
it is prescribed.
7rand:name drugs are capitali>ed and generic
drugs are not capitali>ed in the bod# of thereport, when not in list form.
Dictated: The patient is ta(ing 7extra 15, *#nthroid 6L and
"lexeril 15.
&ranscribed:
$-D'%!T'ON*
The patient is ta(ing
1. 7extra 15 mg.
6. *#nthroid 6L mcg.
). "lexeril 15 mg.
MUCUS/MUCOUS $ucus is a noun.
$ucous is an ad+ective.
is face was smeared with mucus.
The mucous:appearing substance covered his
bod#.
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NUMBERS To promote clarit# of communication in the
health record, most numbers are expressed as
!rabic numerals.
-%-&T'ON*3 Numbers used in non:numeric context are
spelled out.
Numbers indicating stage or ps#ch axis are
oman numeral.
7eginning of sentence, spell out number.
undreds of colonies were noted.
*he has stage '' cancer.
!xis ''
Two lesions were noted on the abdomen.
NUMBER SIGN .<0 Use next to !rabic numbers.
8hen citing case numbers, #ou would use the
s#mbol for number.
' examined the patient on da# - of her hospitali>ation.
%laim 461)5B.
OBSTETRIC HISTORY &! gravida, para, abortus0.
T&!9
T term infants
& premature infants
! abortions
9 living children
4, &), !1.
ravida 4, para ), abortus 1.
4:6:6:4
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*ometimes &! and T&!9 terminolog# are
dictated together.
The patient is gravida ), ):5:5:).
The patient is ), &):5:5:).
PATIENT NAMES eplace patient names with the patientE.
-%-&T'ON3
&s#chiatric patients. Fou can t#pe the patient?s
name, if dictated, onl# in ps#chiatric notes.
The patient presented with cough and congestion.
ohn is here for followup of his obsessive:compulsive disorder.
PENDING DOCUMENT Do not t#pe derogator# or confidential
information on a pending note.
Documents should be pended for the following3
: "'N not found.: T$& documents.
: !ddendum.
:. 7lan(s
: 'ncomplete dictations change to wor( t#pe
CCCC0, but still pend.
!9TIF
'nclude business entit# and short note3
LB3 arbled dictation.
PLUS/MINUS I/:
!s dictated, with the exception3
8rite out the word minus if #ou are not certain
the s#mbol will be noticeable or clear.
*he has I6 edema.
*he is 6 cm dilated, minus ) station, and bag of water is intact.
PREOPERATIVE/POSTOPERATIVE 'f the ph#sician dictates pre: and postoperative,
please use the complete words.
preoperative and postoperative
3UANTITIES *pell out numbers that commence a sentence.
*pell out numeric words in non:numeric
context.
Two small c#sts were removed.
There was another one on the left side.
' observed hundreds of particles.
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3UOTATION MAR-S &eriods and commas alwa#s go inside the
closing ;uotation mar(.
*emicolons and colons alwa#s go outside the
closing ;uotation mar( and the single ;uotationmar(.
! ;uestion mar( or an exclamation point
alwa#s goes inside the closing ;uotation mar(
when it applies onl# to the ;uoted material.
! ;uestion mar( or an exclamation point goes
outside the closing ;uotation mar( when it
applies to the entire sentence.
*he said, ' fell and hit m# head.E
*he screamed, eAs the onePE
Did she reall# sa#, eAs the oneEJ
SAME AS .COPY AND PASTE0 8hen ph#sician dictates preoperative diagnosis
and then sa#s postoperative diagnosis @same@
cop# and paste preoperative diagnosis section to
postoperative diagnosis section.
&-O&-!T'2- D'!NO*'*
!ppendicitis.
&O*TO&-!T'2- D'!NO*'* ph#sician sa#s sameE0
!ppendicitis.
SECTIONS O2 REPORT *eparate sections b# double:space. *O%'!9 '*TOF
The patient denies alcohol or drug use.
"!$'9F '*TOF
"ather with asthma.
SPACING Two spaces follow colons, periods, ;uestion
mar(s and exclamation points.
'*TOF
The patient presents toda# with the complaint of a sore throat. e
will have a chest x:ra#.
&F*'%!9 -!$'N!T'ON
9UN*3 %lear to auscultation.
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SPECI2IC PLACES/TITLES %apitali>e specific places and titles when the#
refer to a specific place and person.
*acred eart ospital -mergenc# oom
' went to the emergenc# room.
The patient was ta(en to the operative suite.
7ett# *mith, .N.
ane Doe, *uperintendent
SUBCUT/SUBCU !bbreviated form for subcutaneous or
subcuticular. T#pe as dictated.
Do not use sub; or subQ.
*ubcut or subcu is acceptable.
TEMPORARY MRN "or all documents that come through without
demographic information and #ou are unable to
find, create a T$& document. &lease pendthese documents. 'nclude the name of patient
dictated on the pend note as well as the top of
the document, and an# other information
dictated b# the ph#sician.
1. &ress !9TI- to get into header.
6. &ress !9TI2 to get to visit grid.
). 8hile in the visit grid, arrow down to the patient number that islabeled @T@ and press spacebar when the empt# box next to the @T@
is highlighted.
4. &ress !9TIO to confirm the changes.
TIME "or on:the:hour expressions, it is preferable not
to add the colon and 55.
$ilitar# time, do not separate hours from
minutes with a colon.
*ee 7oo( of *t#le, pages 6L4:6LL, for time
referents.
M a.m. not M355 a.m.0
M31L a.m.
1)55 hours not 1)355 hours0
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TIMES SYMBOL .X0 Use a lowercase . in expressions of area and
volume.
Use a lowercase . as a multiplication s#mbol.
Use a lower case x when indicating the number
of times something was done or period of time
) x 4 mm lesion
4 x 4 gau>e
46 x )M
The patient had pain x4 da#s.
VERBATIM T#pe verbatim, unless definitel# necessar# to
ma(e a correction.
Use critical thin(ing and discernment.
VERTEBRAL SPACES Use h#phen to express the space between two
vertebrae the intervertebral space0. 't is not
necessar# to repeat the same letter before the
second vertebra, but it ma# be transcribed if
dictated.
't is preferable to repeat the letter before each
numbered vertebra in a list.
*ee 7O*, third edition, pages )C6:)C).
%1:6 or %1:%6
9L:*1.
The lesion involves %4, %L and %=.
WOR- TYPES &lease refer to #our list of wor( t#pes specific
to #our facilit#.
'$&OT!NT3
8O<TF&- U9-* "O DO97-F03
'*TOF !ND &F*'%!93
$ust state '*TOF O" &-*-NT '99N-**
and D'!NO*T'% '$&-**'ON.
'f osteopath, must state
$U*%U9O*<-9-T!9 -!$.
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%ON*U9T!T'ON3
$ust state D'!NO*T'% '$&-**'ON.
D'*%!- *U$$!F3
$ust state "'N!9 D'!NO*'*.
1=
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Appendix I: 2005 JCAHO ro!i"ited A""re#i$tionsBeginning January 1, 2004, JCA! o""er# a li#t o" #tandard a$$re%iation# that they re&uire tran#criptioni#t# not u#e' !ne
can con"u#e or (i#under#tand %ery ea#ily one a$$re%iation )ith another' TE !**+C+A A. !/T+!A + BETASATE.'
The "ollo)ing i# a li#t o" tho#e a$$re%iation# "or your re"erence' JCA! update# thi# li#t "re&uently' eScription #ugge#t# that you %i#itthe JCA! )e$#ite periodically to (aintain a current li#t "or your record#' i#it )))'3caho'org "or an updated li#t o" the#ea$$re%iation#'
1B
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JCAHO Su%%ested option$l &do not use' $""re#i$tions
) ollo* t!e option$l +do not use+ list $s *ell,• All o" the JAC! re&uired A. optional do-not-u#e entrie# )ill $e tran#lated'
g"or (icrogra(5
Mi#ta6en "or (g (illigra(#5re#ulting in one thou#and-"old
do#ing o%erdo#e'
rite 7(cg7
'S'"or hal"-#trength or atina$$re%iation "or $edti(e5
Mi#ta6en "or either hal"-#trength or hour o" #leep at $edti(e5' &''S'
(i#ta6en "or e%ery hour' All canre#ult in a do#ing error'
rite out 7hal"-#trength7 or 7at$edti(e7
T'+''"or three ti(e# a )ee65
Mi#ta6en "or three ti(e# a day or t)ice )ee6ly re#ulting in an
o%erdo#e'
rite 78 ti(e# )ee6ly7
S'C' or S'9'"or #u$cutaneou#5
Mi#ta6en a# S "or #u$lingual, or 7:e%ery7'
rite 7Su$-97, 7#u$97, or 7#u$cutaneou#ly7
.;C
"or di#charge5+nterpreted a# di#continue
)hate%er (edication# "ollo)typically di#charge (ed#5'
rite 7di#charge7
c'c'"or cu$ic centi(eter5
Mi#ta6en "or < unit#5 )hen poorly)ritten'
rite 7(7 "or (illiliter#
A'S', A'.', A'<'atin a$$re%iation "or le"t,
right, or $oth ear#5
Mi#ta6en "or !S, !., and !<,etc'5'
rite= 7le"t ear,7 7right ear7 or 7$oth ear#7
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