Grammar Guidelines in medical Transcription

Abbreviations

      An abbreviation is a shortened, contracted, or brief form of words or phrase. Physicians mostly use abbreviations while dictating in order to speed up communication.  Sometimes, abbreviations can instead lead to confusion in the report or the transcriber can misinterpret them. Some most common examples are COPD, TIA, TAH-BSO, CBC, etc.

When to use Abbreviations?

                      By rule, one must not use abbreviated forms even if dictated in admission or discharge diagnosis, preoperative or postoperative diagnosis, impressions, assessment, or titles of procedure of operative procedure, as these are very crucial points of information in a report and should be expressively communicated.   However, in the remaining narrative portion of the report abbreviations can be used.   However, all other abbreviations should be transcribed in full.  Generally, one must not abbreviate the terms dictated in full except for unit of measurement, for example, milligrams as ml, centimeter as cm. deciliter as dl, which are accepted in the abbreviated form only.  In case of abbreviations having multiple meanings, as in the case of PE which could pleural effusion, pulmonary embolism, pulmonary edema, physical examination, and so on or if the abbreviation is not clearly understandable in cases such as GTT, GGT, GPT, GOT, GT where it becomes increasingly difficult to understand, then it is the transcriptionist’s duty to figure out the correct one by going through the remaining part of the report.  If still unsuccessful, it is better to keep a note rather than end up making a grave mistake.

Usage of periods in Abbreviations

      Abbreviations for degrees or professional credentials (for example: MA, BA) and professional credentials (for example: CMT, RNP), and also courtesy titles like Mr., Mrs., Dr. are used without periods.  Most abbreviations used in medical reports are transcribed without periods, including brief forms, acronyms, and units of measure.  For example, COPD (chronic obstructive pulmonary disease), lab data, cm, WBC.  In case of junior and senior (Jr, Sr), the period is used only when they come in the end of the sentence, not otherwise.  Latin abbreviations used in English communication, like etc. (et cetera), e.g. (exempligratia), i.e. (idest) always take periods and are placed in between commas in a sentence.  Appropriate references should be made use of for the appropriate placement of periods.  Periods are a must when using lowercased drug-related Latin abbreviations like p.o., b.i.d., t.i.d., q.i.d., q.4-6h, etc. If 2 or 3 Latin abbreviations are used together, it is obligatory to put a space between them.  for example:  The patient was advised to take ranitidine p.o. b.i.d. p.r.n. for his acidity.   If the sentence is ending with an abbreviation that has a period, there is no need to add another period.  for example:  the patient is taking ranitidine p.o. p.r.n. (correct), the patient is taking ranitidine p.o. p.r.n. (incorrect).

Abbreviations with Numerals

          A numeral associated with a unit of measure or any associated abbreviation should not be separated. They should always be present in the same line and to do that a non-breaking space should be used.  There are certain abbreviations, which are not written in all capitals but in a mixed pattern like pH, PhO. So always make sure through appropriate references as to which is the correct abbreviated form.

Ampersand or (&)

         An ampersand (&) is a logogram representing the conjunction "and".   It is a symbol, which represents word 'and'.   The name derives from the phrase "and per se and", meaning "and It is used in abbreviations.

For example:  D&C (dilatation and curettage)

  T&A (tonsillectomy and adenoidectomy)

 No space is used before and after ampersand.  As in abbreviations, ampersand is not to be used in diagnosis, operative titles, assessments, and conclusion.

         To form a plural of a capitalized abbreviation, only a lowercase ‘S’ is added. For example,  EKGs, WBCs, PVCs.  In case of lowercased abbreviations, apostrophe 's' is used to make a plural.  For example, wbc's.   In case of short forms for some laboratory terms and some other brief forms also, just 's' is added. For example, segs, lymphs, labs, exams.