Make sure you are following the basics according to the AAMT Book of Style:

q.i.d. not qid or QID
b.i.d. not bid or BID
p.o. not po or PO (now changed to by mouth or orally)
q.h.s. not q. hs or QHS (now changed to bedtime)
q.4-6h. not q. four to six hours
q.d. is now to be written as daily or every day, not q. day or q.d. (See Do Not Abbreviate List Linked Below.)
each week or weekly, not q. week

(in other words, don't mix Latin and English terminology)

1-1/2 packs per day not one and a half packs per day
48-year-old not 48 year old
diabetes mellitus, type 2 (no longer using Roman Numerals)

Capitals:

Do not capitalize departments within the hospital--it is intensive care unit, anesthesia department, emergency room, outpatient clinic, etc.

Remember: No abbreviations in a Final Diagnosis, Discharge Diagnosis, Admission Diagnosis, Assessment, Preoperative Diagnosis, or Postoperative Diagnosis! Expand. If you aren’t sure what an abbreviation means, look it up or ask someone.

(This is per JCAHO and AAMT Style Guidelines)

Hospitals use these Diagnoses for coding purposes. Sometimes an abbreviation may have more than one meaning (PE can mean pleural effusion or pulmonary embolus) and if the dictator has dictated an abbreviation in the diagnosis, it should be expanded. If you are unsure as to what the abbreviation means, then you may have to leave the abbreviation and not expand. But sometimes you are able to tell from what is dictated in the body of the report.

Here is the link for the condensed version of the Style Guide - by getting familiar with it, you are well on your way to becoming a professional MT.

A Source for more Info: http://www.mtdaily.com/style.html

Slang: Many dictators dictate in medical slang. But it is more professional to expand that slang into the proper terminology (remembering you are typing a legal document):

pulse ox to pulse oximetry

temp to temperature

O2 sat to O2 or oxygen saturation

nitro to nitroglycerin (there's no such drug as nitro)

desats to desaturations

alk phos to alkaline phosphatase

segs or segmenters to segmented neutrophils

vent to ventilator or ventilation

crit to hematocrit

preop to preoperative

postop to postoperative

eos to eosinophils

lymphs to lymphocytes

basos to basophils

lap chole to laparoscopic cholecystectomy

appy to appendectomy

bili to bilirubin

ecassa (sounds like "ee-kah-sah") means enteric-coated aspirin

bituli (sounds like "bi-tu-lee") means bilateral tubal ligation

If you know the first and last name of the doctor, it is preferable to type Sam Jones, M.D. or Betty Jones, D.O., rather than Dr. Jones under the special headings in reports. Even in the body of the report, this may be acceptable, even if not dictated, depending on what the dictator/hospital prefers.

1. Challenge yourself.

2. Look up terms, instruments, drugs, common phrases that you are unsure of. Use books, reference materials, or the Internet to increase your knowledge.

3. Become familiar with the terms or phrases that are universally used in all specialties of medicine. That way, no matter what the account or the dictator, you can draw upon your knowledge to help you with the challenge of difficult dictators.

4. Consistently add things to your expansion/short-cut program - normal phrases, drugs, typos, things you are apt to forget.

5. Do a quick proof-read of your document before the job is signed off.

6. Keep in mind that the challenge to yourself is not only how many lines you will do in a day, but how many documents you can do error or blank free.

7. Keep in mind that many other people besides those in the office or the proofers will be looking at your finished product - doctors, ancillary health care personnel, medical records, consultants, medical students or residents, and possibly even the patient or a court of law.

Search WWW Search www.mt-stuff.com

ACE inhibitor (ACE is all caps) (angiotensin converting enzyme)

Ace bandage (only A is capitalized)

ARB (angiotensin receptor blocker)

talc poudrage or talc slurry – sometimes used under thoracoscopy to treat patients with malignant pleural effusions and other lung disorders.

Source: http:/ www.dorlands.com

peau d'orange, [Fr. “orange skin”] a dimpled condition of the skin, resembling that of an orange. (sometimes seen in abnormal breast tissue, for example)

perineum (peri·ne·um) the space between the anus and scrotum, the pelvic floor and the associated structures occupying the pelvic outlet; it is bounded anteriorly by the pubic symphysis, laterally by the ischial tuberosities, and posteriorly by the coccyx.

perineal – pertaining to the perineum.

peritoneum (peri·to·ne·um) the serous membrane lining the abdominopelvic walls (parietal p.) and investing the viscera (visceral p.). A strong, colorless membrane with a smooth surface, it forms a double-layered sac that is closed in the male and is continuous with the mucous membrane of the uterine tubes in the female. The potential space between the parietal and visceral peritoneum is called the peritoneal cavity.

peritoneal – pertaining to the peritoneum.

vesical (ves·i·cal) pertaining to the urinary bladder.

vesicle (ves·i·cle) a small sac containing liquid, usually a clear fluid.

aural - pertaining to the ear.

oral - pertaining to the mouth.

Please feel free to print and distribute any of the reports from this web site. My only requirement is that you give credit to this web site by placing the referral note below back to this site:

If you do use these sample reports for students or classes, please let me know. My goal for this web site is to mentor future MTs to carry on our professional craft and legacy; I would like to know I helped in some small way to achieve that goal.
Thank you and May God Bless You,
Rosemarie