Book Of Medical Transcription

BOOK OF MEDICAL
TRANSCRIPTION

A SHORT GUIDE FOR MEDICAL & TRANSCRIPTION
LANGUAGE

PART - I

Table of Contents

CHAPTER 1
Introduction to Medical Transcription
Healthcare Laws
CHAPTER 2
Medical Specialties

Hospital Care Team Members

Medical Worktypes
CHAPTER 3

AAMT/AHDI Book Of Style

JCAHO Guidelines

CHAPTER 4

Error Calculation

INTRODUCTION TO MEDICAL TRANSCRIPTION

Medical transcription, also known as MT, is an allied
health profession dealing with the process of
transcribing voice-recorded medical reports that are
dictated by physicians, nurses and other healthcare
practitioners.

Medical reports can be voice files, notes taken during a
lecture, or other spoken material. These are dictated
over the phone or uploaded digitally via the Internet or
through smart phone apps.

Medical transcriptionist is someone who listens to a
provider’s dictations and types them verbatim (word-
for-word). The provider may be dictating outside of the
room before or after examining the patient.

The dictation is usually and essentially that – a provider’s word-for-word account of what they
saw/touched/diagnosed during the encounter.

Doctors, nurse practitioners, and other healthcare
providers dictate their confidential notes about
each visit. Transcriptionists take these notes and
transcribe them into a comprehensive record of
the visit.

They use a template based on the type of practice,
with most specialties having different
requirements.

Sometimes they receive files that are unedited
speech-to-text translations. They then edit and
format these notes and turn them into a finished
document.

There are some necessary skills required for medical transcriptionists, which they always need to be learn
mandatorily:

 Typing speed
 Typing accuracy
 Medical knowledge
 Grammar, spelling and punctuation

accuracy.
 Active listening
 Attention to details
 Time management skills
 Critical thinking skills

Medical transcription profession is not just listening and converting voice data into text; it involves
high responsibilities. Even small errors might lead to unwanted consequences and put lives under
threat. Hence, it is essential that medical transcription professionals are properly trained and are up-
to-date.

FUNDAMENTAL US HEALTHCARE LAWS &
REGULATIONS FOR MEDICAL
TRANSCRIPTION PROVIDERS
With focus on securing sensitive patient health
information, certain important legislations have
been enacted during the recent past. Different
processes in the current medical industry are
required to adhere to such standards and legal
mandates as HIPAA and privacy rules. Failing to
comply or adhere with the legal requirements will
result in legal sanctions and heavy penalties. It is imperative that professional medical
transcriptionists and transcription service providers keep themselves updated with the latest
legislative norms and needs.

Code Of Ethics

For security of Patient Personal Information, there are a few codes of ethics that must be followed by
medical transcriptionists. These are aimed at protection of confidentiality and privacy of patient
information. Legal requirements demand complete protection of patients’ personal information and
management of the same in a highly secure manner by authorized persons.

Essential Rules and Regulations in Medical Transcription

The following are the codes of ethics developed by the Association for Healthcare Documentation
Integrity (AHDI) that serve as important guidelines and are considered to function as a framework
for professional medical transcriptionists and medical transcription companies:

 Patient Information Confidentiality
o A primary requirement related to medical transcription companies is confidentiality of patient

information – this includes data security in electronic communications
 Individuals’ dignity and rights must be honored
o Unique needs of individuals must be clearly understood and their dignity and rights must be respected
 Timely and accurate information
o Medical transcription service providers must relentlessly strive to offer accurate information on time

 Professional standards in transcription
practice

o Standards of professional transcription
practice needs to be properly maintained

 Compliance with standards and rules
o All rules, laws, and regulations governing

patient data documentation must be
complied with

HIPAA, A Legislative Act…

Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a federal
law that required the creation of national
standards to protect sensitive patient health
information from being disclosed without the
patient’s consent or knowledge.

Who Has To Be HIPAA Compliant –

1. Covered Entities
2. Business Associates (we)

Covered Entities are

 Healthcare Providers
 Healthcare Plans
 Healthcare Clearing Houses

Rules For Protecting PHI

THE PRIVACY RULE – This rule establishes national
standards to protect individuals' medical records and
other individually identifiable health information.

THE SECURITY RULE - This rule establishes national
standards to protect individuals' electronic personal
health information that is created, received, used, or
maintained by a covered entity.

THE BREACH NOTIFICATION RULE - If a breach affects 500 or more individuals, covered entities must
notify the Secretary without unreasonable delay and in no case later than 60 days following a
breach. If, however, a breach affects fewer than 500 individuals, the covered entity may notify the
Secretary of such breaches on an annual basis.

Why Does It Matter To A MT??

 It is the law
 It ensures that any personal information that a MT come

into contact with will remain safe and protected.

What Are The Potential Consequences If A MT Violate
HIPAA??

 Civil penalties including fines
 Potential disciplinary action up to and including termination
 Criminal liability depending on severity of the breach

MEDICAL SPECIALTIES IN USA

The medical field is as expansive and multifaceted as the intricacies of the human body. Doctor
specialities exist for each of these fields of medicine to serve the need of a particular realm of care.
Every medical specialist has very specific skills and competencies that make them an integral
member of the medical field.

1. Allergy and Immunology: This department works with patients suffering from allergies and diseases
of the respiratory tract or immune system.

2. Anesthesiology: It is the branch of medicine
dedicated to pain relief for patient before,
during and after surgery.

3. Dermatology: Dermatologists treat patients
with disorders of the skin, hair, nails and
adjacent mucous membranes.

4. Diagnostic Radiology: These physicians are
trained to diagnose illnesses in the patients
throughout the use of x-rays, radioactive
substances, sound waves in ultrasounds or
the body’s natural magnetism in MRIs.

5. Emergency Medicine: These physicians
provides care to patients in emergency
situations. These specialists provide
immediate decision making and action to save
lives and prevent further injury.

6. Family Medicine: Family Medicine focuses on
integrated care and treating the patient as a
whole.

7. Internal Medicine: Internist is a physician who treats diseases of the heart, blood, kidneys, joints,
digestive, respiratory and vascular systems of adolescent, adult and elderly patients.

8. Neurology: Neurology is the speciality within the medical field pertaining to nerves and nervous
system.

9. Nuclear Medicine: Nuclear medicine radiologists use radioactive materials to diagnose and treat
diseases.

10. Obstetrics and Gynecology: OB/GYNs care for the female reproductive system and associated
disorders.

11. Ophthalmology: Ophthalmologists diagnose and treat vision problems.
12. Pathology: A physician specializing in pathology studies the causes and nature of diseases. Through

microscopic examination and clinical lab
tests, pathologists work to diagnose,
monitor, and treat diseases.
13. Pediatrics: These physicians work to
diagnose and treat patients from infancy
through adolescence.
14. Physical Medicine and Rehabilitation: These
specialists work to help patients with
disabilities of the brain, spinal cord, nerves,
bones, joints, ligaments, muscles and
tendons. Physiatrists work to improve
patient quality of life rather than seek
medical cures.
15. Psychiatry: Physicians specializing in
Psychiatry devote their careers to mental
health and its associated mental and physical ramifications.
16. Radiation Oncology: Radiation oncologists treat cancer with the use of high-energy radiation
therapy. These physicians work with cancer patients prescribing and implementing treatment plans
while monitoring their progress throughout.
17. Surgery: General surgeons provide a variety of live saving surgeries.
18. Urology: Urology is the health care segment that cares for the male and female urinary tract and
also deals with the male sex organs.
19. Podiatry: Branch of medicine devoted to the study, diagnosis, medical and surgical treatment of
disorders of the foot, ankle and lower extremity.

ADDITIONAL INFORMATION: Description

Sr. Subspecialty This medical speciality deals with seriously or critically
No ill patients who are at the risk of or are recovering
1 Critical Care Medicine/Intensive from conditions that may be life threatening
Palliative care is specialized medical care for people
Care Medicine living with a serious illness. Palliative care is meant to
enhance a person’s current care by focusing on quality
2 Palliative Care of life for them and their family (It starts around at
around diagnosis and treatment level). It deals with

3 Pain Management the patients who have serious, but not considered to
4 Sleep Medicine be life-threatening for now.
5 Medical Toxicology It is an aspect of medicine involving relief of pain in
various dimensions.
6 Sports Medicine This subspecialty devoted to the diagnosis and
therapy of sleep disturbances and disorders.
7 Undersea and Hyperbaric This subspeciality of medicine focusing on toxicology
Medicine and providing the diagnosis, management and
prevention of poisoning and other adverse effects due
8 Geriatric Medicine to medications, occupational and environmental
9 Advanced Heart Failure and toxicants and biological agents.
This branch of medicine deals with physical fitness
Transplant Cardiology and the treatment and prevention of injuries related
to sports and exercise.
10 Cardiovascular Medicine Hyperbaric Medicine involves the prevention of injury
11 Electrophysiology and illness from exposure to environments with
12 Endocrinology increased ambient pressure and the therapeutic use
of high environmental pressure and the delivery of
13 Gastroenterology oxygen under the high pressure to treat disease.
14 Hematology and Oncology Medical speciality focused on providing care for the
unique health needs of older adults.
15 Infectious Disease Speciality focuses on management of advanced or
complicated heart failure beyond the scope of what is
16 Interventional Cardiology usually provided by general internists and general
17 Nephrology cardiologists
18 Pulmonary Medicine Branch of medicine that deals with disorder of the
19 Rheumatology heart and the cardiovascular system
Branch of Cardiology focusing on the electrical
activities of the heart
Branch of medicine dealing with the endocrine
system, treats all ailments concerning all glands in the
human body.
Branch of medicine focused on the digestive system
and its disorders.
This type of medicine diagnoses and treats cancerous
blood disorders and manages symptoms of these
diseases and resultant tumors.
Consists of managing nosocomial (health-care
acquired) infections or community acquired
infections.
Branch of Cardiology that deals specifically with the
catheter based treatment of structural heart diseases.
Concerns the diagnosis and treatment of kidney
disease.
Often involves managing patients who need life
support and mechanical ventilation.
Branch of medicine devoted to the diagnosis and
management of disorders whose common feature is
inflammation in bones, joints, muscles and internal
organs.

20 Hepatology Branch of medicine that incorporates the study of

liver, gallbladder, biliary tree and pancreas as well as

management of their diseases.

21 Maternal Fetal Medicine (MFM) Perinatology is a branch of medicine that focuses on

managing health concerns of the mother and fetus

prior to, during and shortly after pregnancy.

22 Oculoplastics Includes surgical procedures that deal with the orbit,

eyelids, tear ducts and the face as well as

reconstruction of the eye and associated structures.

23 Clinical Pathology Medical speciality that is concerned with the diagnosis

of disease based on the laboratory analysis of bodily

fluids using the tools of chemistry, microbiology,

hematology, molecular pathology and

immunohematology.

24 Forensic Medicine The application of medical and paramedical scientific

knowledge to certain branches of law.

25 Medical Microbiology Branch of medical science concerned with the

prevention, diagnosis and treatment of infectious

diseases.

26 Occupational Medicine Focuses on the diagnosis and treatment of work-

related injuries and illnesses

27 Public Health and Preventative Science and art of preventing disease, prolonging life

Medicine and promoting health through the organized efforts

28 Colorectal Surgery/Proctology Field in medicine dealing with disorder of the rectum,

anus and colon.

29 Plastic Surgery Surgical specialty involving the restoration,

reconstruction or alteration of the human body

30 Craniofacial Surgery Surgical subspecialty that deals with congenital and

acquired deformities of head, skull, face, neck, jaws

and associated structures.

31 Hand Surgery Deals with both surgical and nonsurgical treatment of

conditions and problems that may take place in the

upper extremity including injury and infection.

32 Oral and Maxillofacial Surgery Surgical specialty focusing on reconstructive surgery

of the face for facial trauma; oral cavity, head and

neck, mouth and jaws as well as facial cosmetic

surgery including cleft lip and cleft palate surgery.

33 Otolaryngology/head and neck Surgical subspecialty within medicine that deals with

surgery/ENT the surgical and medical management of conditions of

the head and neck.

34 Orthopedics Branch of surgery concerned with conditions involving

the musculoskeletal system.

35 Speech Language Pathology (SLP) SLPs specialize in the evaluation, diagnosis, treatment

and prevention of speech and language impairments,

cognitive communication disorders, voice disorders

and swallowing disorders

36 Trauma Medicine Study of wounds and injuries caused by accidents or

violence to a person and the surgical therapy and

repair of the damage.

37 Bariatric Surgery Includes a variety of procedures performed on people

who are obese

38 Neonatology Subspecialty of pediatrics that consists of the medical
care of newborn infants, especially the ill or
39 Cardiothoracic Surgery premature newborn.
40 Vascular Surgery Field of medicine involved in surgical treatment of
organs inside the thoracic cavity
41 Male Infertility Surgical subspecialty in which diseases of the vascular
42 Hospice system or arteries, veins, and lymphatic circulation are
managed by medical therapy, minimally-invasive
catheter procedures, and surgical reconstruction

Hospice Care focuses on the care, comfort and quality
of life of a person with a serious illness who is
approaching the end of life (it starts with end of
treatment for terminally ill)

HOSPITAL CARE TEAM MEMBERS

Depending on the care that is needed, a hospital care team includes many different practitioners.

Attending physician - the attending physician is the leader of the team and has responsibility for
all decisions made that affect a person's care, including diagnosis, treatments, and supervision of
the remainder of the team.

Residents, interns, and medical students (house staff) - a resident or intern is a fully licensed
doctor who is engaged in further training after graduating from medical school.

Specialists - the specialist may be a doctor who is extensively trained in the diagnosis and
treatment of disorders of the medical specialties.

Registered nurses (RN) - people usually have more contact with the registered nurses (RNs)
assigned to their care. RNs may be charge
nurses or nurse supervisors, organizing and
monitoring overall nursing care in a hospital
unit.

Licensed practical nurses (LPN) - Licensed
practical nurses (LPNs) are supervised by RNs
and provide basic medical and nursing care.

Nurse practitioners (NP) and physician’s
assistants (PA) - nurse practitioners and
physician’s assistants (PAs) work closely with
the attending physician to coordinate a
person's daily care. Although nurse
practitioners and PAs are not doctors, they
have advanced training in diagnosis and treatment. Nurse practitioners and PAs are supervised by
doctors.

Social workers - social workers provide support, information, and education.

Dietitians - registered dietitians have specialized nutritional and medical training that helps them
determine a person's dietary needs

Interpreters - for deaf or hard-of-hearing people and for people whose first language is not
English, hospitals provide an interpreter who has special skills in medical terminology.

Rapid response team - rapid response teams are groups of designated hospital staff who quickly
come to a person's hospital room if there is any indication that their condition is deteriorating.

TYPES OF WORKTYPES IN MEDICAL TRANSCRIPTION
Medical transcription is a process that functions at the periphery of the healthcare industry. It is the
process of converting dictations of the healthcare professionals into well-formatted text documents.
It plays a vital role in creating the patient’s medical history which is used for reference by healthcare
providers, medical practices, insurance companies, and lays a foundation for future patient visits.

There are different types of medical transcription reports that a physician can request.

 History and Physical report: This report is usually dictated by physicians when a patient is admitted
to the hospital. It starts with the main complaint, followed by history of the patient’s current illness,
medical history, social history and family medical history. This is regarded as the complete physical
examination of the patient and ends with an admission diagnosis and a plan of treatment.

 Consultation report: This is dictated by the physician to whom the admitting physician has referred
the patient. The consulting physician is usually a specialist in an area other than the admitting
physician. It also includes a small description about the illness of the patient and a specific physical
exam based on the type of consultation requested. It may also include x-ray or laboratory findings.
This report concludes with the physician’s impression and treatment plan.

 Operative report: This report is dictated by the operating physician, which includes a detailed
description about operative procedure. Details include pre-operative and post-operative notes, the
type of surgery, name of the surgeon, anesthesiologist, and a detailed description of the operative
procedure itself. Based on the type of surgery, the count of instruments, blood loss etc are also
mentioned. The report will end with disposition or where the patient was transferred when she left
the operating room and the overall health condition of the patient.

 Radiology report: This report is dictated by the radiologist once the diagnosis and radiology
procedures are completed. It includes the radiologist’s findings and interpretations of x-rays, CT
scans, MRI scans, nuclear medicine procedures and so on.

 Pathology report: This report is dictated by the pathologist and includes the microscopic findings of
the sample.

 Laboratory report: This report includes the findings of examinations of bodily fluids such as blood
levels and urinalysis. This report is rarely dictated separately but often included in the H&P,
consultation or discharge summary.

 Discharge summary: This report is dictated by the physician at the end of the patient’s stay at the
hospital. All crucial reports right from the admission of the patient until discharge will be included.
The report ends with a detailed plan for the patient. If this report is transferred to another
institution, then it changes from discharge summary to transfer summary. If the patient dies, then it
will be called death summary.

 Office reports/Clinic notes: Reports that are created in a medical practitioner’s office not treated as
hospital reports. Some of these are initial evaluations, letters to referring physicians, patient
introduction letters to specialists, and chart notes for each visit.

Accurate medical transcripts contain important medical data of patients for future reference.
Doctors go through these medical transcripts and charts to review patient evaluations and decide
which treatment is best suitable. A minor error in the transcript or a misspelling of medicine or
dosage can cause major health issues or even lead to death. Therefore, accurately transcribing
doctors’ dictation into well-documented reports is essential to ensure patient safety and better
healthcare service.

AAMT/AHDI BOOK OF STYLE

AAMT & AHDI:
AAMT is abbreviated as American Association for Medical Transcription (MT). Now this has changed
to The Association for Healthcare Documentation Integrity (AHDI).

This is a
n American society that is responsible to set standards in the field of health care. Since MT falls
under the health care category, AAMT sets standards like pricing, accuracy and security.

AHDI releases a book of style with updated rules in medical transcription.

Here are some Medical Transcription rules, which every MT should know and must be followed
while transcribing.

1. DO NOT TYPE A SPACE
 before or after a hyphen
 before or after a slash
 before or after a dash

 between a number and percent sign

 parentheses and the enclosed material
 between any word and the punctuation following it.
 between the number and the colon used to indicate a dilute solution or ratio, e.g. 1:4
 on either side of the colon when expressing the time of day
 before an apostrophe
 before or after a comma used within numbers
 before or after an ampersand in abbreviations, e.g., C&S
 on either side of the colon when expressing ratios e.g. 1:1
 after the closing parenthesis if another mark of punctuation follows
 when using the word “times” as x – e.g., x3

TYPE ONE SPACE…

 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 type 2 spaces...
 after punctuation at the end of a sentence

 after a colon except when expressing time or a dilution ratio
2. NUMBERS

 Spell out WHOLE numbers zero through nine, use numerals for 10 and above (this may change in the
near future as the AAMT is trying to standardize using numerals only.

 Use numerals when numbers are directly used with symbols.
 Use numerals when expressing ages.
 If it is an approximate age, spell it out.
 Use numerals to express size and measurements.
 Use numerals for everything metric. Centimeters, millimeters, liters, etc.
 Use numerals in all expressions pertaining to drugs - this includes strength, dosage and directions. Z-

PAK 2 daily on day 1, then 1 daily on days 2-5.
 Spell out and hyphenate fractions standing alone. He drank one-half a gallon of apple juice.
 Use numerals to express mixed fractions. 1 1/2 years.
 Use commas only if there are 5 or more digits when expressing numbers. e.g. 10,000, 4000.
 Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and

respiration.
 Substitute a hyphen for the word "to". He is to take 1-2 tablets of Tylenol every 4-6 hours p.r.n.
 Leave a space between numerals and measurements unless they form a compound modifier. It is 6

cm below the ...... It is 1200 mL....... A 4-cm nevus....... A 2 x 2-mm lesion.......
 Always use 0 in front of the decimal point if the number is not a whole number. 0.75 mg
 Use decimal fractions with metric measurements. 1.5 cm
 Use mixed fractions with English system measurements. 1 1/2 inch
 Use numerals for: Ages, units of measure, vital statistics, lab values and in other instances where it is

important to communicate clearly the number referenced. Examples: 4 inches, 3-year-old. She has
three dogs who have eight fleas each. A total of 7 basal cell carcinomas removed from his left arm.
(7 for clarity)
 Do not start a sentence using a number. Spell out the number or recast the sentence.

 Dictated as: 10 milligrams of Reglan was administered stat. Transcribe as: Reglan 10 mg was
administered stat.

 Exception - It is acceptable to begin a sentence with a date. Example - 2004 is going to be a
prosperous year.

 Plurals - do not use an apostrophe to form plural numbers.
 4 x 4s
 She was in her 20s or twenties (this is acceptable because it is not a definite number).
 She was born in the 1970s.
 Series of numbers - Use numerals if at least one is greater than nine or if there is a mixed or decimal

fraction.
 Example - Jeff has 1 job, 1 place of employment and 18 hours a day to do the work.
 Cranial nerves - Preferred: Roman numerals I-XII
 Diabetes type 1 and type 2, not Roman numerals I and II - this was recently standardized by the

American Diabetes Association.
 Apgar scores - Use numerals for ratings and spell out numbers relating to minutes. Rationale - to

draw attention to the scores. Example: The Apgar scores were 6 and 9 at one and five minutes.
Apgar is not an acronym.

 Time Examples
 8:30 a.m. - morning
 8:30 p.m. - evening
 noon, not 12:00 noon
 midnight, not 12:00 midnight or 12 'o'clock or 12:00 p.m.
3. MEASUREMENTS

 Spell out all nonmetric measurements. Feet, inches, pounds, ounces, yards, grain, dram, etc.

 Exceptions:
 Use tsp for teaspoon
 Use tbsp for tablespoon
 Abbreviate all metric measurements.
 Use F for Fahrenheit IF accompanied by the symbol for degree. 98.6°F
 Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit.
 Use C for Celsius IF accompanied by the symbol for degree. 36°C
 Spell out Celsius IF degree is spelled out. 36 degrees Celsius.

 In tables and technical documents:
 Use ft or ' for feet
 Use " for inches
 Use yd for yard
 Use pt for pint
 Use oz for ounce
 Use fl oz for fluid ounce

 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%

4. SYMBOLS

 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 4-5
 Number 3 0 #3-0
 Twenty-twenty vision 20/20
 BP 120 over 80 120/80
 Grade two over six 2/6
 A positive A+
 Three point five centimeters 3.5 cm
 Point five centimeters 0.5 Cm
5. CAPITALIZE

 Abbreviations when the words they represent are capitalized
 The first word following a colon if it begins a complete sentence or is part of an outline entry
 Most abbreviations of English words
 The first letter of chemical elements
 The names of the days of the week, months, holidays, historic events and religious festivals
 The names of specific departments or sections in the institution only when the institution name is

included
 The names of diseases that include proper nouns, eponyms or genus names
 The trade or brand names of drugs
 A quote when it is a complete sentence
 The names of races, peoples, religions and languages. Black, as a race designation would be

capitalized, however client preferences may differ.

Do Not Capitalize...

 The spelled out names of the chemical elements
 The seasons of the year
 The common names of diseases
 The names of viruses unless they include a proper noun
 Generic drug names
 The common noun following the brand name. Example - Tylenol tablets
 The names of medical or surgical specialties
 Designations based on skin color, like "a tall white man."
6. HYPHENATION

 These prefixes do not require the use of a connecting hyphen in compound terms:
 Ante, intra, semi,
 Anti, micro, sub,
 Bi, mid, super,
 Co, non, supra,

 Contra, over, trans
7. STAGE, TYPE AND FRACTURE CLASSIFICATIONS

 Lowercase the words "stage" and "type," and use roman numerals. For subdivisions of stages, follow
The AAMT Book of Style rules for cancer classifications, and add on-line capital letters without
spaces or hyphens:

 Examples
 complex regional pain syndrome stage I
 stage II-III
 type I radioulnar synostosis
 type II open fracture
 type IIIB
 Garden II femoral neck fracture
 Salter VI fracture
8. GRADE

 Lowercase the word "grade" and use arabic numerals:
 Examples:
 grade 1 chondromalacia patellae
 grade 2
 grade 3-4

 9. LEVEL, PHASE AND CLASSLowercase the words "level," "phase," and "class," and use arabic or
roman numerals according to the system being referenced:

 Examples:
 Radiation Therapy Oncology phase III
 Haggitt level 4 colorectal adenocarcinoma
 physical status class 2E

10. WRIST ARTHROSCOPY PORTALS

 Use arabic numerals. Two numbers should be hyphenated without spaces; add on-line capital letters
with no space:

 Examples:
 1-2 portal
 portal 3-4
 6U wrist portal

JCAHO RULES

WHAT ARE JCAHO GUIDELINES??
Commission on Accreditation of Healthcare Organizations (JCAHO) — a private, nonprofit organization
dedicated to improve the quality of care in organized healthcare settings.

Joint Commission standards are the basis of an objective evaluation process that can help health care
organizations measure, assess and improve performance. The standards focus on important patient,
individual, or resident care and organization functions that are essential to providing safe, high quality care.

To meet this JCAHO goal, organizations must standardize the abbreviations, acronyms, and symbols used
throughout their organization. This includes developing a “Do Not Use” list of abbreviations, acronyms, and

symbols. Beginning January 1, 2004, JCAHO requires the following dangerous abbreviations, acronyms and
symbols be included on each accredited organization’s “Do not use” list.

JCAHO FORBIDDEN ABBREVIATIONS

Abbreviations Potential Problem Preferred Term
U Mistaken for zero, four or cc Write “unit”
(for unit)
IU Mistaken for IV (Intravenous) or Write “international unit”
(for International Unit) 10 (ten).
Q.D., Q.O.D. Mistaken for each other. The Write “daily” or “every other
(Latin abbreviation for once daily period after then Q can be day”
and every other day) mistaken for an “I” and the O can
be mistaken for “I” Never write a zero by itself after
Trailing zero (X.0 mg), lacking of Decimal point is missed. a decimal point (X mg), and
leading zero (.X mg) always use a zero before a
Confused for one and another. decimal point (0.X mg)
MS Can mean morphine sulfate or Write “morphine sulfate” or
MSO4 magnesium sulfate “magnesium sulfate”
MgSo4

In addition, effective from April 1, 2004, each organization must add at least another three “do not use”
abbreviations, acronyms and symbols to the organization’s “Do Not Use” list. The JCAHO suggests selecting
from the following:

OTHER NOT TO BE USED ABBREVIATIONS, ACRONYMS ND SYMBOLS

Abbreviations Potential Problem Preferred Term
µg Mistaken for mg (milligram) Write “mcg”
resulting in one thousandfold
H.S. (For half-strength or Latin dosing overdose Write out “half-strength” or “at
abbreviation for bedtime) Mistaken for either half-strength bedtime”
T.I.W or hour of sleep (at bedtime) Write “3 times weekly” or “three
(for three times a week) Mistaken for threentimes a day times weekly”
or twice weekly resulting in an
S.C. or S.Q. overdose Write “Sub-Q”, “subQ” or
(for subcutaneous) Mistaken for SL for sublingual or subcutaneously
D/C “5 every” Write discharge.
(For discharge) Interpreted as discontinue
whatever medications follow Write “ml” for “milliliters”
c.c. (typically discharge meds).
(for cubic centimeter) Mistaken for U (units when Write “left ear,” “right ear” or
A.S., A.D., A.U. (Latin poorly written) “both ears;”, “left eye,” “right
abbreviation for left, right or Mistaken for each other (e.g., AS eye” or “both eyes”
both ears), O.S., O.D., O.U. (Latin for OS, AD for OD, AU for OU,
abbreviation for left, right or etc.)
both eyes )

The Institution Of Same Medication Practices (ISMP) has also published a list of dangerous abbreviations
relating to medications use. This list is available at www.ismp.org. Examples for this list are:

Abbreviations Potential Problem Preferred Term

> and < Mistakenly used opposite of Use “greater than” or “less than”
/ (slash mark) intended
Misunderstood as the number 1 Do not use a slash mark to
(“25 units/10 units” read as “110 separate doses. Use “Per”
units”)

Whenever any prohibited item has been used in an order, there must be written evidence of confirmation of
the intended meaning before the order is carried out. If, in the judgment of the people providing care to the
patient (e.g., the registered nurse and pharmacist), the order is clear and complete and the delay to obtain
confirmation from the prescriber prior to execution of the order would place the patient at greater risk, then
the order should be carried out and the confirmation obtained as soon as possible thereafter.1 Through the
end of 2004, JCAHO will limit the survey and score of this requirement to all handwritten, patient-specific
documentation, not just orders. As of 2005, the requirement will also apply to preprinted forms and software
that contain the prohibited items.

ERROR CALCULATION IN MEDICAL TRANSCRIPTION

Accuracy in Medical Transcription – A Point That Can Save A Life

When dealing with medical documentation, errors are not just inconvenient, they can be outright
dangerous to the patient.

A formula is used to calculate typing accuracy when it comes to medical documents.

In this formula, errors are assigned a “point value”. Acritical error is given a higher point value than
a minor error and the expected degree of accuracy is 98%.

To calculate the point value of errors, the ADHI generated a scale of what was considered
unacceptable.

 Critical errors – 3 points
 Major errors – 1 to 1.5 points
 Minor errors – 0.25 to 0.5 points
 Administrative/Educational – 0 point

In 2017 this scoring system was reviewed to remove the Major Error category, with items within that
been either being promoted to a Critical Error or redefined to a Noncritical Error Category worth 1
point, Minor errors and Administrative/Educational errors remain the same.

DEFINITIONS OF DIFFERENT CATEGORIES OF ERRORS

A critical error is one which

 Adversely impacts on patient safety
 Alters a patients’ care or treatment/
 Adversely impacts the accuracy of coding and billing
 Results in a HIPPA violation
 Adversely affects medicolegal outcomes

Some example of this would include things like incorrect terminology which alters or obscures or is
opposite to the intended meaning (hypo-/hyper-, known/no, regular/irregular), incorrect medication
(including name, dose/dosage, unit of measure and method of administration), incorrect side/site
(left/right, peroneal/perineal), use of unapproved abbreviations, omitted or inserted (“note/bloat”)
text, failure to flag critical inconsistencies/discrepancies, use of confusing words/phrases.

A noncritical error impacts on document integrity but does not have the potential to affect patient
safety, care or treatment.

Examples would include incorrect spelling of medication or terminology, punctuation that
alters/obscures meaning, nonsense text, incorrect medical homophones, and failure to follow the
Style Guide or individual account specifics.

Differentiation between Minor and Administrative/Educational errors are at the discretion of the
organisation. Companies may choose to limit the number of Repetitive Educational errors within a
report, or may upgrade repetitive educational feedback as a minor error.

These would include things like grammar/punctuation/misspelling (other than mentioned above),
capitalisation (e.g., generic drug names if required by account specifications), incorrect English
homophones.

Reasons Why Errors In Transcription Occur?

Errors in medical transcription can occur in different ways. Some of the most likely causes for the
errors in medical transcription are:-

 Transcriptionists don’t know the medical jargons that
doctors use

 The prescribed records are in a non-standard format
resulting in contradictory comment or lack of
information

 Deficient sound quality makes it impossible for a
transcriptionist to grasp the dictation

 Words that confuse the transcriptionist with the correct
information

 Insufficient quality reviews of the transcribed
documents

Effective Ways To Avoid Medical Transcription Errors

1. Pay Attention to the Audio
What you can do is first listen to the audio and then go through the accurate interpretation after
having a good and precise comprehension of the recordings. It will assist you to overcome the errors
to 100%.

2. Quality Check is a Must

If the medical transcription is complete, proofreading must be made. The higher the number of
accuracy tests, the smaller the probability of paper mistakes.

----------------------------------------------------------------END OF PART 1 ---------------------------------------------------------