Do Not Type a Space ... following a period with an abbreviation 

I.V. following a period used as a decimal

point  1.2 between quotation marks and the

quoted material  “squeaky sounds” in ears

before or after a hyphen  mid-August before or after a slash  allergies/ immunology

before or after a dash  50-70% between a number and percent sign  50% between parentheses and the enclosed

material  Irritable bowel syndrome (resolved)

between any word and the punctuation following it.  Irritable bowel syndrome, resolved.

between the number and the colon used to indicate a dilute solution or ratio.  1:2 ratio was used in his anesthesia.

on either side of the colon when expressing the time of day  12:00 p.m.

before an apostrophe  The patient’s mother was present during this evaluation.

before or after a comma used within numbers  15,000

before or after an ampersand in abbreviations, e.g., C&S, T&A

on either side of the colon when expressing ratios e.g. 1:1 

after the closing parenthesis if another mark of punctuation follows  Irritable bowel syndrome (resolved).

between words  after a comma  after a semicolon  after a period following an initial  after the closing parenthesis  on each side of the x in an expression

of dimension, e.g. 4 x 4 

after punctuation at the end of a sentence 

after a colon except when expressing time or a dilution ratio 

after periods on itemized or enumerated data under plan/assessment. Example: 1. (2 tab spaces) Return to see me in 2 weeks.

**Numbers: Spell out the numbers 1 to 9 if they are referring to an English word, or if they are referring to an approximation. Zero is generally spelled out. Numbers 10 and above should always be in figures.

Use Numerals for clarity and so they stand out from the text. The patient was brought to the ER 1 hour after the

accident. The patient has been seen 3 times in the last month. Height 5 foot 5 inches, weight 130 pounds. There are exceptions to every rule.  Use your judgment and

keep in mind that clarity is always the goal. You may sometimes encounter numbers in approximation, but followed by a unit of measure. This is an EXCEPTION to our rule.

D: Approximately 5 mL of blood loss. T: Approximately 5 mL of blood loss.

Approximate Numbers There were hundreds of patients in the emergency

room. The patient is approximately six years old The patient is approximately 60 years old. The patient is about two months postoperative

now. The abrasion was about 1 cm in size.  

Adjacent Numbers - Spell out two consecutive numbers to avoid confusion. Take two 275 mg tablets daily. Alor 5/500 one to two tablets q.4-6 h. p.r.n. Three 2-inch bandages. Use a comma between neighboring and unrelated

numbers when neither can be easily expressed in words and the sentence cannot be reworded.  E.G. During the month of June 1999, 5299 prescriptions were dispensed.

Fractions - According to the dictation style, spell out or use numerals for common fractions D:  One and one-half hours ...  T:  1-1/2 hours ... He smokes two packs and a half of cigarettes per

day. He smokes 2½ packs of cigarettes per day. He smokes 2-1/2 packs of cigarettes per day. 

(Note the use of the hyphen in mixed fractions if the subscript is not used.)

He has a 30-pack-year cigarette habit. Use decimal fractions with the metric system.  1.5

cm Use common fractions with the English system.  1-

1/2 inch

Beginning a Sentence - Do not use a numeral to begin a sentence.  Spell out the number or recast the sentence. D:  10 mg of Reglan was administered stat.  T:  Reglan 10 mg was administered stat. Exception - It is acceptable to begin a sentence with

a year, although recasting the sentence is preferred. 

Acceptable:  2000 is going to be a prosperous year.  Preferred:  The year 2000 will be prosperous.

Plurals - With single-digit numbers, use ‘s 4 x 4's To form the plural of multiple-digit numbers, do not

use an apostrophe She was in her 30s He was last hospitalized in the 1970s

Arabic Numerals (0, 1, 3, etc.) Versus Roman Numerals - as a general rule, most numbers will be expressed in Arabic numbers unless Roman numerals are specified or preferred.

Grades are generally expressed in Arabic numbers. grade 4/6 murmur CIN grade 3 or  CIN-3 Developmental dysplasia, Crowe grade II

(Exception - Not Crowe grade 2)

Stages are generally expressed in roman numerals especially with CANCER staging, with some exceptions stage III decubitus ulcer ovarian cancer, FIGO stage IV stage 3 Garden fracture (Exception -

Not stage III Garden fracture) Diabetes - The American Diabetes

Association adopted the use of Arabic numbers for clarity. Diabetes type 1 Diabetes type 2

Cranial Nerves - Roman numerals are preferred. Cranial Nerves I-XII

Apgar Scores - Use numerals for ratings and spell out numbers relating to minutes to draw attention to the scores.  Apgar is not an acronym. The Apgar scores were 6 and 9 at one and five

minutes Zero - The number zero is spelled out when

standing alone. There was zero response to the medication. The temperature outside dropped to zero. Always use a zero in front of a fractional number

less than zero 0.75 mg 0.25 mm

Ordinals - Ordinal numbers are used to indicate order or position in a series rather than a quantity.  Ordinals are commonly spelled out, especially when the series goes higher than 10 items.  However, as with all numbers in medical reports, AAMT recommends using numerals:  1st, 2nd, 3rd, 4th, etc. Do not use a period with ordinal numbers. 3rd rib (or third) 5th finger (or fifth) She is to return for her 3rd (or third) visit

in 2 days. She was in her 9th or (ninth) month of

pregnancy. His return visits are scheduled for the 15th

and 25th of next month.

Commas - Use commas only if there are 5 or more digits when expressing numbers 4000 10,000

Time- Use numbers separated by a colon, except for even periods of time.  Do not use colons with military time.  Do not use numbers for midnight and noon. The office closes at 8 a.m. Her appointment was at 10 a.m. MILITARY HOURS:  2300 hours, 1500 hours, 0830

hours Noon, not 12 p.m. or o’clock; midnight, not 12 a.m.

or o’clock

Transcribe dates in full. Example:

D: Blood was drawn on 10-11-05.T: Blood was drawn on October 11, 2005.D: Admitted on February twenty secondT: Admitted on February 22 NOT 22nd

D: Admitted on the second of FebruaryT: Admitted on the 2nd of February.D: Admitted on February the secondT: Admitted on February the 2nd.D: Admitted on the second of February of this yearT: Admitted on February 2, 2006

*Complete date format. D: Admitted on February of this year. T: Admitted on February 2006.

*Delete the word of. This is assuming that the date of report is current. D: On February of two thousand and six, she was admitted for… T: On February 2006, she was admitted for…

EDUCATIONAL LEVELS:D: second grade T: 2nd gradeD: fourth year in high schoolT: 4th year in high school

RANGES:D: two to fours daysT: 2 to 4 days (not hyphenated)D: approximately two to four daysT: approximately two to four days (approximation)D: ten to fifteen percentT: 10-15% (hyphen due to the symbol) or 10% to 15%D: ten to fifteen hertzT: 10 to 15 HzD: L4 to S1 T: L4 through S1D: L4 dash 5T: L4-L5

Use tsp for teaspoon  Use tbsp for tablespoon 

Spell out Fahrenheit IF degree is spelled out - 98.6 degrees Fahrenheit.

Spell out Celsius IF degree is spelled out. 36 degrees Celsius.

If dictated, spell out degrees. 98.6 degrees

If degrees not dictated, do not transcribe degrees. 98.6

Abbreviate most unusual units of measure when accompanied by numerals

Dictated as Transcribed as

0.8 centimeters squared 0.8 sq cm

22 millimeters of mercury  22 mmHg

3.0 liters per minute 3.0 L/min

40 millimeters per hour  40 mm/h

8 grams percent  8 gm%

Spell out a symbol when used alone (with no number). 

Use symbols when they are used with numbers 

Common Symbols 

Dictated as Transcribed as

Four to five 4 to 5 

Number 3 0  #3-0 

Twenty-twenty vision 20/20 

BP 120 over 80 120/80 

Grade two over six 2/6 

Three point five centimeters  3.5 cm 

Point five centimeters 0.5 cm

Capitalize... Abbreviations when the words they represent are

capitalized  Autism Spectrum Disorder/Pervasive Developmental Disorder (ASD/PVD)

The first word following a colon if it begins a complete sentence or is part of an outline entry  HEENT: Normocephalic

Most abbreviations of English words  I.V. The names of the days of the week, months, holidays,

historic events and religious festivals  Wednesday, February, Thanksgiving…

The names of specific departments except when it follows the word consult, ward/suite Neurology but radiology consult, pediatric ward 

The trade or brand names of drugs  A quote when it is a complete sentence

The seasons of the year  winter, spring, summer, fall

The common names of diseases  Generic drug names  The common noun following the brand

name. Example - Tylenol tablets  Designations based on skin color, like

"a tall white man." 

Use hyphens when numbers are used with words as compound modifiers preceding nouns. 3.0-mm Johnson & Johnson stent a #7-French sheath or a 7-French

sheath when the word “number” is not dictated

5-cm incision 3 x 2-cm mass 13-year 2-month-old girl The patient is 34-year-old woman,

but the woman is 34 years old.

Use hyphens to join some compound nouns with numbers as prefixes.  Check appropriate references for specific terms.

Use hyphens in compound numbers from 21 to 99 when they are written out.  Note:  The only time they should be written out is at the beginning of a sentence. twenty-five three hundred eighty-nine

A hyphen versus to/through The values are accompanied by a symbol.

Examples: He is to take 1 to 2 tablets of Tylenol

every 4 to 6 hours p.r.n. Blood pressure was in the 140 to 160

range Office hours are 1 through 4 p.m. There is a 40-50% occlusion

Ante Intra semi

Anti Micro sub

Bi mid super

Co Non supra

Contra Over trans

Counter Pre tri

De post  ultra

Extra Pro un

Infra Pseudo under

Inter re  weight

Examples - antecubital not ante-cubital  Also Correct - antithesis, bitemporal, counterproductive, defibrillated, extrapyramidal, infraumbilical, interpersonal, intracranial, microhematuria, midline, nontender, nondistended, nonfocal, nonspecific, noncontributory, noncompliance, nonicteric, nonsmall, overestimate, overweight, preoperative, postoperative, posttraumatic, pseudogout, semicircular, sublingual, superimposed, supramammary, transvaginal, ultraviolet, underweight, weightbearing.

BUT: mid-August, mid-July…

Do use a hyphen with prefixes ending in a or i and a base word beginning with the same letter. Example - anti-inflammatory.

Do use a hyphen when compounded with the prefix self.  Example - self-administered drugs, self-monitored vitals. 

For Clarification - Use a hyphen after a prefix if not using a hyphen would change the meaning of the word.  Examples - re-cover (to cover again) versus recover (regain) 

Stage and grade - do not capitalize either one if it does not begin a sentence. 

Use Roman numerals for cancer stages.  Use Arabic numerals for cancer grades.  For clarity, use capital letters or arabic

suffixes without spaces or hyphens.

stage 0 

stage I stage IA 

stage II 

stage III  stage IIIA stage IIIB

stage IV 

grade 1 

grade 2 

grade 3 

grade 4 

If dictated q.day - transcribe q.d.  If dictated q. four hours - transcribed as q.4 h.

or every 4 hours not q. 4 hours When referring to drugs including strength,

dosage and directions - Use Arabic numerals only.  Example - The patient was prescribed penicillin 500 mg t.i.d. for 5 days. 

If there is no whole number, always add a 0 in front of the decimal point for clarity - this is a general rule when transcribing numbers, not just medications.  Example - Dictated as Synthroid point 75 mg a day. 

Transcribe as Synthroid 0.75 mg q.d.  Of note also (as seen in the example above),

transcribe a day as q.d. when referring directly to the medication frequency. Twice a day for b.i.d., three times a day t.i.d. and four times a day, q.i.d.

Be aware that some drugs are commonly dictated in either milligrams or micrograms. Example -  Synthroid 0.05 mg or Synthroid 50 mcg.

Vitamins Unless it begins a sentence, use lowercase - vitamin.

Capitalize the letter, if available use subscript for the number.  Do not leave a space between letter and number:  B12 or B12

Use commas to separate multiple related test results. Here are some examples:  Creatinine 1.2, BUN 42, phosphorus 4.3.  WBC 12.4 with 72 segs, 9 lymphs.  CBC reveals an RBC count of 10.2, WBC 6.8, platelets

220,000, reticulocyte count 1 with 3 monos, 1 eos and 0 basos. 

Electrolytes reveal a serum sodium of 138, potassium 4.0, chloride 100 and glucose of 80. 

Use periods or semicolons (as necessary) to separate unrelated laboratory test results. For example,  Potassium 3.7. TSH 1.0. Albumin 4.0. 

Laboratory tests include potassium 3.7; TSH 1.0; and albumin 4.0.

Names with junior or senior attached. Use a comma before and a period after the abbreviation or use neither.  Example - Jeramiah Johnson, Jr. or Jeramiah

Johnson Jr  Incorrect - Jeramiah Johnson Jr. 

Names with ordinals. Do not use comma between name and ordinal.  Example - Bernie Schwartz III  Incorrect - Bernie Schwartz, III 

BUT IF FORMATTED AS LAST NAME, FIRST NAME: Johnson, Jeramiah, Jr. and Schwartz, Bernie, III

You will encounter dictators saying “He” or “She” at the start of the report. You should edit this to become “The patient”. This is to identify the patient. After you have identified the patient, then it is alright to transcribe he, or she in the succeeding sentences. Example:

D: He is here today for a follow up for his graft. He was last seen on…

T: The patient is here to today for a follow up for his graft. He was last seen on…

Edit the obvious grammatical errors and inconsistencies in patient’s sex. If you cannot determine the actual sex of the patient, then edit the pronouns to become “the patient.”

Do not start a sentence with the word “also,” even if dictated. You should recast the sentence.

Be very careful with your punctuations. You do not need to supply articles and prepositions if

not dictated, and if the sentence can stand on its own. Itemize the diagnoses/assessment and plan if more

than one was dictated. Itemize discharge medications in a Discharge

Summary. Put a comma before the words “but” and “which” if

there are more than four words after them. Edit redundancies, but be very careful not to alter the

style of the dictator. Always transcribe the words laboratory and

examination in full even if dictated as labs and exam

History of Present Illness - Mainly in present tense, but mixed tense may be appropriate. 

Or REASON FOR VISIT or CHIEF COMPLAINT The main reason for consultation

Then either SUBJECTIVE: If all data under this heading

contains, the patient states/denies/says/notes IF NOT USE HISTORY:

Past Medical History - Use past tense. BUT: The patient has hypertension NOT the

patient had hypertension. (since hypertension is a condition that is currently present)

Allergies are typed either ALL CAPITAL LETTERS if not drugs or medication or bold font for medications. 

Example - If the allergy is dictated latex, type LATEX. If dictated as allergy is Cymbalta, type Cymbalta.

Transcribe in continuous paragraph format, except when the doctor numbers the medications.  Example: Penicillin 500 mg t.i.d. for 5 days, levothyroxine 0.75 mg q.d. and Lopressor 50 mg b.i.d. 

Capitalize brand name medications. DO NOT capitalize generic medications. 

Use Latin drug abbreviations when dictated.  Example - if dictated every day - transcribe q.d.  If dictated every four hours - transcribe every 4 hours. 

Don't mix Latin and English terminology.  Example:  If dictated q. day - transcribe q.d. NOT q. day. 

When referring to strength, dosage and directions - Use Arabic numerals only. 

If there is no whole number, add a zero in front of the decimal point for clarity. This is a general rule when transcribing numbers, not just medications. Example:  Dictated as Synthroid point 75 milligrams a day. Transcribe Synthroid 0.75 mg q.d.

Transcribe in present tense whenever applicable or as dictated. 

Subheadings under review of systems should contain only the systems while under physical examination subheadings should be specific anatomical part even if dictated as system.

Examples: REVIEW OF SYSTEM: GENITOURINARY (even if dictated as urinary

tract) PHYSICAL EXAMINATION: SKIN (even if dictated as dermatologic)

No abbreviated medical terminology.  Type the entire term or phrase.  Example - If the doctor dictates CAD, type coronary artery disease. PNA transcribe as either PERMANENT or PARTIAL NAIL AVULSION (ANALYZE THE SENTENCE)

Numbers follow the same rules for any section of the transcript.  Example - A 31-YEAR-OLD FEMALE.  5 MG. 

Anatomical parts are not spelled out. MTPJ, DIPJ

Use past tense:  In the past history of a report  In discharge summaries EXCEPT for the History of

Present Illness and the Physical Examination sections. 

When discussing expired patients  Use present tense:

To describe mostly information under physical examination

Use the correct verb tense to communicate the appropriate time of the action. Even if the dictator inadvertently changes tense during the dictation. 

Fill in blanks or make notes Consistent pronouns - he or she?  Consistent tense - was or is?  Singulars versus plurals - sclera or

sclerae? Headings - Are they labeled properly?  Sound-alike: heel vs. heals; maybe vs.

may be

Unnecessary awkward repetitions or redundancies

No abbreviations in diagnoses except anatomical parts when dictated as such.

Drugs correctly capitalized Formatting, headings and indentations Proper use of hyphens Dates Complete sentences Punctuation