When transcribing the typing tests, some students change the tenses to match.
The provider will dictate: The patient is here with his wife. He was very nauseous. The student will want to change the tense of “was” to “is” to match the first sentence. Although this does make sense normally, while transcribing the typing test it is not permissible.
Students must type verbatim.
Numbers are an ongoing source of frustration for medical transcriptionists.
The AAMT is in the process of changing the rules for numbers. At the present time the safest bet is to use numerals. Some items could go either way, but the numbers that should ALWAYS be typed as numbers would be ages, units of measure, numbers 10 and higher, etc. An exception to this would be two numbers in a row, such as twelve 4-0 Ethilon sutures. That is the correct way. You would not type 12 4-0 as that is confusing to the eye.
But, no matter what is considered the correct way, the provider’s preference trumps everything else.
How do I know when to use lie versus lay? This is a question many medical transcriptionists, and actually the general population, have queried.
Lay requires an object and lie does not. Example would be “you lie down on the exam table” and “you lay the baby down”, with the baby being the object.
These, of course, are present tense. Past tense gets a bit trickier and we will cover that in a future article.
Why is “well-nourished Caucasian woman” acceptable but “Caucasian woman is well-nourished” not? It is because it all depends where the noun is. If the hyphenated words are before the noun, hyphen is fine; after the noun, no hyphen. So, a “3 x 5-mm scar” is okay as well as “the scar is 3 x 5 mm” but “the scar is 3 x 5-mm” is not correct. One of the easier rules of this wonderful yet quite often complicated English language!
Punctuation is everything…
An English professor wrote: “A woman without her man is nothing”on the chalkboard and asked his students to punctuate it correctly.
All of the males in the class wrote, “A woman, without her man, is nothing.”
All the females in the class wrote: “A woman: without her, man is nothing.”
Does punctuation really matter? As this example proves, it really does! So many times we ask ourselves, should there be a comma there? When do I use a semicolon? Does it really matter if I leave that colon out? As you can see just in this one example alone, yes, punctuation is very important as a simple comma or colon or any other form of punctuation can change the meaning of the entire sentence.
To all you future MTs reading this, please take note!
Is it follow-up, followup, or follow up? How can eight simple letters be so confusing? This simple word, or two, is responsible for many periods of ponderation. First and foremost, in the transcription field we no longer use follow-up. So, with that option eliminated let’s move on to the remaining two choices.
Followup is a noun whereas follow up is an adjective. “The patient will schedule a followup” as opposed to “the patient will follow up”. One very easy way to remember which one to use is this simple rule: If you can put an “A” in front of the word then it would be followup; if not, then use follow up. One less thing to wonder about!
Quite often I have been asked about the “do-not-use dangerous abbreviation” list. The worry by the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) is that these abbreviations can be misread. While that certainly is a possibility, speaking from a professional medical transcription and proofreader standpoint I can assure you that the majority of these abbreviations are indeed used and used often.
The most common suspect culprit abbreviation is q.d. for every day or daily. This particular one is typed thousands of times a day so please do not be swayed by this “dangerous” list. If the provider/dictator you are typing for deems it in appropriate, well, their preference is the final say, but otherwise, please continue to use q.d. on a q.d. basis!
Numbers, numbers, numbers. For such a seemingly simple digit or digits they sure can wreak havoc on the MT-in-training’s cranium. Old rules, new rules, providers preferences, AAMT rules. The information can be contradictory and confusing. The “old” AAMT rules still in effect to a certain extent are to spell out numbers up to 9, unless it refers to age, date, vitals, measurements, etc. This will all be changing soon as the industry is trying to standardize numbers and everything will be numeral. But even when that takes effect, the provider/dictator still has final say on his or her preference. Once again remember, to have a successful career in Medical Transcription you must be flexible and adaptable!
As you can probably imagine, we frequently get questions related to Medical Transcription grammar and format rules. Most of our training is by textbook, but many of our examples are taken from our employers. One of our objectives is to introduce you to variety in Medical Transcription styles so you can adapt more easily once you are employed.
Grammar won’t make or break your career as an MT. The reason is that style can be very subjective. It’s good to learn the basics and then be flexible when you go to work with your future employer – they will determine “house rules” which override all other sources of information.
Stressing over these issues is counter productive because there isn’t a universal answer in many cases. There can be two correct answers or even more! It is a much better idea to move along more quickly and keep the Big Picture in mind; you don’t have to be perfect. The Big Picture goal is to be employed so you can use your flexible skills.
You can use these quizzes to learn several ways of doing things. The AAMT Book of Style is excellent and is our style bible, but it is trumped by “house rules” or “doctor rules”.
Many students have problems with grammar. Med Workshops addresses grammar at length. For an additional source of reference, see this site if you need help.