Transcribing/

Transcribing/Editing Tips

Although these tips can be found throughout your study materials (The AAMT Book of Style is an excellent resource), the following tips bear repeating:

PREFIXES

	In most cases, do not hyphenate to join prefixes, including ante-, anti-, non-, mid-, peri-, post-, pre-, semi-, and sub-. Examples: antepartum, antianxiety, nontender, midplane, perimenopausal, postoperative, premenstrual, semicircle, subcutaneous. If in doubt, join the prefix with the word and see if it goes through the spell checker.
	Prefixes do require a hyphen if it would have another meaning without the hyphen, e.g., re-cover (cover again), recover (locate again).

METRIC MEASUREMENTS

Use the decimal form with metric measurements, even if dictated as a fraction, e.g., 4.5 mg (not 4-1/2 mg), 3.75 cm (not 3-3/4 cm).

FOLLOW UP, FOLLOW-UP, AND FOLLOWUP. Although there are variations to the rule, here is how I prefer to see "follow up."

	Followup (adjective) is to be used when modifying a noun, e.g., The patient is to have a followup Pap smear in six months. Note: Follow-up is also acceptable when used as an adjective.
	Follow up (verb). The patient should follow up in three weeks.
	*Followup* (noun). This patient is seen in followup today.

ABBREVIATIONS/ACRONYMS

	Spell out abbreviations in diagnosis (assessment or impression).
	Spell out abbreviations the first time they occur in the body of the report. Example: "The patient has a history of BPH (benign prostatic hypertrophy). His BPH is followed by Dr. Smith in Urology."

VITAL SIGNS -- PREFERRED FORMAT

Blood pressure 140/69. Height 5 feet 9-1/2 inches. Weight 198 pounds. Respirations 20. Pulse 72.

TYPING NUMBERS

According to AAMT’s new style guidelines, all numbers should be typed in Arabic format, e.g., “A 4-year-old female with a 3-day history of pruritic rash.” I would imagine if your employer has another preference that they let you know when you start working.

Sometimes you will want to alternate how you type numbers for clarity. Examples:

	She is to take one 5-mg Valium p.r.n.
	We will perform three 24-hour studies on this patient.
	Ten years ago, this patient had a colonoscopy. (Always spell out numbers at the beginning of a sentence).
	The surgeon made two 5-cm incisions.
	There were 65 lymphs, 2 monos, and 5 eos.
	The patient is a 5-year-old female.
	A mass was noted at the 2 o'clock position in the right breast.
	The patient is taking digoxin 0.125 mg q.d.
	Anesthesia was 0.5% Xylocaine.
	The distal two-thirds of the esophagus revealed no abnormalities.

Situations That Require Editing

Simple editing includes adding punctuation, making a word singular when it is dictated as plural, or correcting subject-verb agreement. If the dictation makes sense, rule of thumb is to leave it as is. If the dictation is missing an obvious piece of information that you can verify as correct, or if slight rephrasing makes the content clearer, you may edit in these situations.

MTs identify the following inaccuracies in word use as acceptable to edit:

	Tense. Physicians frequently change tense from present to past while dictating. Choose a tense and use it consistently.
	Articles a and an. Use a before words beginning with a consonant sound; use an before words beginning with a vowel or vowel sound.
	Prepositions. Use a more accurate preposition when warranted. For example, change into to in in the following statement: “An incision was made into the artery.”
	Forms of a word. Improve awkward phrasing in dictation. For example, change refilling to refill in the following statement: “He will need a refilling of his medications.”
	Made-up words. Physicians sometimes coin words (“unrevealing,” for example) or combine words that are difficult to verify. Use your dictionary and the context to make the correct choice.