uch specifications

8/18/2019 Uch Specifications

http://slidepdf.com/reader/full/uch-specifications 1/18

Florida Hospital TampaFlorida Hospital CarrollwoodFlorida Hospital at Connerton

Helen EllisZephyrhills

02/01/2012

The eScription Style GuideEditScript-MT

Customer (AHS) Defined Style Guide

1



EDITING/TRANSCRIPTION STANDARDS

WORD/PHRASE CORRECT USAGE EXAMPLE

A, AN Use a before a consonant

Use a before a sounded h

Use a before a long u

Use an before a vowel

Use an before an unsounded h

a patient

a hemorrhoid

a unit

an indication

an hour

ABBREVIATIONS/ACRONYMS Use approved abbreviations as dictated unless

in the diagnosis section, procedure

diagnosis/name sections or operative

diagnosis/name sections.

Laboratory an !a"no#t!$ !%a"!n" t&#t# DO

NOT need to be expanded, even in above

sections.

!" should be expanded to lobal !ssessment

of "unctioning in the diagnosis section of all

ps#ch reports.

There is no s#novitis of the $%&s, &'&s or D'&s. There is some

s#novial thic(ening of the left )rd D'&.

D'!NO*'*

*#novitis of the left )rd distal interphalangeal +oint.

&O%-DU-

Total abdominal h#sterectom#.

T! dictated, but expanded as above in this section0

'$&-**'ON

$' shows intracranial hemorrhage.

!'* 2

lobal !ssessment of "unctioning3 45.

6



!bbreviations are acceptable for units of

measure when used with a number0, dosages,

diagnostic tests and laborator# wor( for

exceptions, please see below0.

The abbreviation --NT can be used in the

ph#sical examination.

There are two abbreviations for hemoglobin

7 and gb0. 8e will be using HGB. *o,

hemoglobin A1c can be abbreviated HGB A1c.

Please Note: 8hen t#ping hemoglobin A1c,

please ma(e sure that #ou are t#ping a 1 and not

a l .

!lthough ph#sicians dictate sed rate, the actual

abbreviation is -* er#throc#te sedimentationrate0 and not sed. 'f the ph#sician dictates sed

rate, t#pe sedimentation rate. 'f the ph#sician

dictates ESR, use the abbreviation.

Do not abbreviate medications.

Do not use abbreviations when referring to the

e#es3 OD, OS, OU

9atin:based abbreviations3 !lwa#s place

periods between each letter for fre;uenc# of

medications.

Un!t# o' M&a#(r&%&nt) cm, mm, m-;, (g, mg, m9, mcg

Do#a"&#) b.i.d., t.i.d., p.r.n., p.o., n.p.o.

T&#t#) $', %T, -$/N%2, --, -<, !&!, %7%, 7N&.

--NT3 -#es are clear. -ars are clear.

left e#e, right e#e, both e#es

'N%O-%T %O-%T

npo n.p.o.

po p.o. prn p.r.n.

;am ;.a.m.

;pm ;.p.m.;id ;.i.d.

tid t.i.d.;4h ;.4h

;=h ;.=h

)



&lurali>e acron#ms b# adding ?s?

&9-!*- *-- T- O""'%'!9 @DO NOT

U*-@ 9'*T !T T- -ND O" T'*

DO%U$-NT.

DTs, !D9s, &2%s, 87%s.

ABDUCTION/ADDUCTION 'f the ph#sician dictates ab:duction, t#pe

abduction.

'f the ph#sician dictates ad:duction, t#pe

adduction.

abduction

adduction

*ABLE AND +IBLE There is no shortcut in determining whether a

word ends in able or !ible. %onsult adictionar#.

AGE 8hen a ph#sician dictates a patientAs age at the

beginning of a sentence, do not add a or an.

&ut the word the at the beginning of the

sentence.

The patient is a B:#ear:old bo# who was hit b# a car.

The )C:#ear:old male presents with a histor# of tuberculosis.

A-A Use lowercase letters with periods . The patientAs name is $ar# *mith a"#"a" $ar# Thornheart.

A LOT, ALOT AND ALLOT The phrase a lot means to a considerable

;uantit# or extentE and is al$a%s written as two

words. DO NO& SPE'' &H(S PHRASE AS

ONE )ORD. A'O& (S NO& A )ORD"

Allot means to distribute or assign.

Than(s a lot .

Fou will have to allot a portion of next #earAs budget to bu# a new

computer.

ALLERGIES %apitali>e all drug allergies. NO <NO8N DU !99-'-*.

&-N'%'99'N, -FTO$F%'N, 9!T-.

4



AMPERSAND .0 Do not use GHA. 't does not cross the interface

to %erner correctl#.

Use GandA instead.

ASSESSMENT AND PLAN *hould read @D'!NO*T'% '$&-**'ON.@ D'!NO*T'% '$&-**'ON%hronic obstructive pulmonar# disease.

AUDIO !9T I * will @un>ip@ audio silences. *#mbol

on toolbar will have a red line when un>ipped,

so #ou can hear silent parts/missed parts of

dictation.

BLAN-S Two ;uestion mar(s and five underscores.

Time stamp on transcribed documents.

Time stamp not necessar# on edited documents.

JJKKKKK

BREA-S/LUNCHES 1. @&ause@ function for brea(s L:15 minutes0.

6. *ign:out for lunch.

Do not use !9TI*'"TIU for lunch as it (eeps

documents in #our ;ueue.

The s#stem trac(s time that #ou are signed on, so using these

functions more accuratel# represents #our production time.

BUSINESS ENTITIES 2erif# correct business entit#. 'f not correct,

please change.

!9TI- and !9TI7 for business entit#.

CAPITALI1ATION %apitali>e ma+or/section headings.

Do not capitali>e department names, unless

meaning is ambiguous.

!lwa#s capitali>e3

!$!3 !!'N*T $-D'%!9 !D2'%-.

DN'3 DO NOT 'NTU7!T-.

'*TOF O" &-*-NT '99N-**

&!*T $-D'%!9 '*TOF

The patient was induced b# !nesthesia.

L



DN3 DO NOT -*U*%'T!T-.

%OD- 79U-, -D. !99 %OD-*0

DU!79- &O8- O" !TTON-F

%apitali>e allerg# section.

Do not capitali>e diagnoses.

NO <NO8N DU !99-'-*.&-N'%'99'N !ND -FTO$F%'N.

'2 DF-.

D'!NO*-*

1. %holelithiasis.

6. #pertension.

). !sthma.

CONTRACTIONS Do not use contractions unless #ou are

specificall# ;uoting an individual.

The patient did not have his insurance card.

*he stated, ' didnAt get #our message until 15 p.m.E

DASHES AND SLASHES Do not use in headings.

Do not use in ranges. Use the word @to@

instead.

Use onl# when necessar# in bod# of report.

The patient will return in ) to 4 wee(s.

DATES D!T-* O" *-2'%-3

'*TOF !ND &F*'%!93 Do not t#pe

date, unless dictated.

D'*%!- *U$$!F3 !dmission and

discharge dates.

!99 OT- 8O< TF&-*3 'nclude date of

service as date dictated, unless otherwise

indicated b# dictator.

Use virgule t#pe M:digit date. $$/DD/FFFF

=



8hen onl# month and #ear given, please

promote clarit#.

$$/FFFF

DEGREES "lexion to 45 degrees 8rite out degrees. Do not use the s#mbol.

DIAGNOSIS/DIAGNOSES 'f there is more than one diagnosis, the heading

is D(AGNOSES"

D'!NO*'*

!ppendicitis.

D'!NO*-*

1. !ppendicitis.

6. %holelithiasis.

DISCHARGE DIAGNOSIS *hould read @"'N!9 D'!NO*'*.@ "'N!9 D'!NO*'*

Diverticulosis.

"'N!9 D'!NO*-*1. Diverticulosis.

6. #pertension.

DOCTOR &ut period after @Dr.@ Dr. ones.

EXAMINATION/EXAM T#pe as dictated unless in a heading &F*'%!9 -!$'N!T'ON

is exam was negative.

2OLLOW*UP, 2OLLOWUP AND

2OLLOW UP

'f used an ad+ective or noun, t#pe followup or

follow:up.

'f used as a verb, t#pe follow up 6 words0.

The patient will have a followup chest x:ra#.

"ollow:up should be in = wee(s.

The patient will follow up in ) wee(s.

2RACTIONS T#pe as fractions Do not write them out, unless

at the beginning of a sentence.

No superscript.

There is edema about 6/) the wa# up on the calf.

Two:thirds of her calf is swollen.

B



2RE3UENCY @x@ abutted next to the number. The patient was alert and oriented x).

GRADES/STAGES/TYPES !!7'% NU$7- D-NOT!T'ON1. rades of conditions and diseases.

6. %ranial nerves.

). T#pes of conditions and diseases.

O$!N NU$7- D-NOT!T'ON

1. *tages of conditions and diseases.

6. *alter:arris fracture.

). &s#chiatric diagnoses D*$0.

rade 6/= s#stolic murmur.

%'N grade 1, 6, ), or %'N 1, 6, ) this is a grade, not stage/t#pe0

%ranial nerves 6:16.

Diabetes mellitus t#pe 6.

*tage '' decubitus ulcer.

*tage '' cancer.

*alter:arris t#pe '.

!'* ', !'* ''.

HEADINGS AND SUBHEADINGS !ll ma+or headings are capitali>ed, no colon,

with text on next line single space underheading at left margin0.

'f a heading is not dictated but understood,

insert the appropriate heading.

!ll headings and subheadings are left:margin

+ustified. *ubheadings are to be capitali>edwith a colon followed b# two spaces, and then

text.

'*TOF O" &-*-NT '99N-**

The patient is a BL:#ear:old male.

&F*'%!9 -!$'N!T'ON

-N-!93 e is alert and oriented x).

'*TOF O" &-*-NT '99N-**

The patient is a =L:#ear:old male who presented with chest pain

and d#spnea. heading not dictated, but understood due to nature

of this text0.

&F*'%!9 -!$'N!T'ON

--NT3 Nose and throat are clear.*<'N3 8arm and dr#.

9UN*3 %lear to auscultation.

M



No repetition of text in relative heading.

TYPE VERBATIM HEADINGS .E4$&5t!on)

Do6b&y r&7(!r&# $&rta!n 8&a!n"# !n HP,

Con#(6t# an D!#$8ar"& S(%%ar!&# + S&&

9Wor: Ty5&#;0

REMOVE ALL UNUSED HEADINGS

'N%O-%T3

&!*T $-D'%!9 '*TOF

&ast medical histor# is positive for asthma.

%O-%T3

&!*T $-D'%!9 '*TOF

&ositive for asthma.

HEIGHT, INCHES AND POUNDS Do not use s#mbols for feet and inches.

"ractions are separated b# a h#phen.

*pell out the word *o+nds.

The patient was = feet 4 inches.

The patient is L feet 4:1/6 inches.

The patient weighed 665 pounds.

HYPHENATION 9imited h#phenation, onl# when necessar# for

h#phenated compounds.

!lwa#s h#phenate patient?s age.

Do not use h#phen for ranges. Use the word

@to@ instead.

"inger:to:nose test.

8ell:developed, well:nourished female.

igh:power field.

This is a 46:#ear:old male . . .

The patient is a 6:1/6:month:old infant with . . .

The patient will return in ) to 4 months.

LISTS Denote lists with number, period, two spaces,

and then text.

1. #pertension.

6. %hronic obstructive pulmonar# disease.

C



MEASUREMENTS Use numbers for fractions in dimensions.

!lwa#s put a 5 in front of a fraction that begins

with a decimal.

Use abbreviation for associated measurement

1.L cm

5.L cm

$-!*U-$-NT !77-2'!T'ON

%entimeters cm

<ilograms (g

$icrograms mcg

$illie;uivalents m-;

$illigrams mg

$illiliters m9

$illimeters of mercur# mmg

MEDICATIONS T#pe in list format.

'f dictated in paragraphed format, still create a

list.

$edications should alwa#s contain the

appropriate unit of measure if dosage is

dictated. 'f the ph#sician does not dictate the

unit of measure, #ou must loo( it up to see how

it is prescribed.

7rand:name drugs are capitali>ed and generic

drugs are not capitali>ed in the bod# of thereport, when not in list form.

Dictated: The patient is ta(ing 7extra 15, *#nthroid 6L and

"lexeril 15.

&ranscribed:

$-D'%!T'ON*

The patient is ta(ing

1. 7extra 15 mg.

6. *#nthroid 6L mcg.

). "lexeril 15 mg.

MUCUS/MUCOUS $ucus is a noun.

$ucous is an ad+ective.

is face was smeared with mucus.

The mucous:appearing substance covered his

bod#.

15



NUMBERS To promote clarit# of communication in the

health record, most numbers are expressed as

!rabic numerals.

-%-&T'ON*3 Numbers used in non:numeric context are

spelled out.

Numbers indicating stage or ps#ch axis are

oman numeral.

7eginning of sentence, spell out number.

undreds of colonies were noted.

*he has stage '' cancer.

!xis ''

Two lesions were noted on the abdomen.

NUMBER SIGN .<0 Use next to !rabic numbers.

8hen citing case numbers, #ou would use the

s#mbol for number.

' examined the patient on da# - of her hospitali>ation.

%laim 461)5B.

OBSTETRIC HISTORY &! gravida, para, abortus0.

T&!9

T term infants

& premature infants

! abortions

9 living children

4, &), !1.

ravida 4, para ), abortus 1.

4:6:6:4

11



*ometimes &! and T&!9 terminolog# are

dictated together.

The patient is gravida ), ):5:5:).

The patient is ), &):5:5:).

PATIENT NAMES eplace patient names with the patientE.

-%-&T'ON3

&s#chiatric patients. Fou can t#pe the patient?s

name, if dictated, onl# in ps#chiatric notes.

The patient presented with cough and congestion.

ohn is here for followup of his obsessive:compulsive disorder.

PENDING DOCUMENT Do not t#pe derogator# or confidential

information on a pending note.

Documents should be pended for the following3

: "'N not found.: T$& documents.

: !ddendum.

:. 7lan(s

: 'ncomplete dictations change to wor( t#pe

CCCC0, but still pend.

!9TIF

'nclude business entit# and short note3

LB3 arbled dictation.

PLUS/MINUS I/:

!s dictated, with the exception3

8rite out the word minus if #ou are not certain

the s#mbol will be noticeable or clear.

*he has I6 edema.

*he is 6 cm dilated, minus ) station, and bag of water is intact.

PREOPERATIVE/POSTOPERATIVE 'f the ph#sician dictates pre: and postoperative,

please use the complete words.

preoperative and postoperative

3UANTITIES *pell out numbers that commence a sentence.

*pell out numeric words in non:numeric

context.

Two small c#sts were removed.

There was another one on the left side.

' observed hundreds of particles.

16



3UOTATION MAR-S &eriods and commas alwa#s go inside the

closing ;uotation mar(.

*emicolons and colons alwa#s go outside the

closing ;uotation mar( and the single ;uotationmar(.

! ;uestion mar( or an exclamation point

alwa#s goes inside the closing ;uotation mar(

when it applies onl# to the ;uoted material.

! ;uestion mar( or an exclamation point goes

outside the closing ;uotation mar( when it

applies to the entire sentence.

*he said, ' fell and hit m# head.E

*he screamed, eAs the onePE

Did she reall# sa#, eAs the oneEJ

SAME AS .COPY AND PASTE0 8hen ph#sician dictates preoperative diagnosis

and then sa#s postoperative diagnosis @same@

cop# and paste preoperative diagnosis section to

postoperative diagnosis section.

&-O&-!T'2- D'!NO*'*

!ppendicitis.

&O*TO&-!T'2- D'!NO*'* ph#sician sa#s sameE0

!ppendicitis.

SECTIONS O2 REPORT *eparate sections b# double:space. *O%'!9 '*TOF

The patient denies alcohol or drug use.

"!$'9F '*TOF

"ather with asthma.

SPACING Two spaces follow colons, periods, ;uestion

mar(s and exclamation points.

'*TOF

The patient presents toda# with the complaint of a sore throat. e

will have a chest x:ra#.

&F*'%!9 -!$'N!T'ON

9UN*3 %lear to auscultation.

1)



SPECI2IC PLACES/TITLES %apitali>e specific places and titles when the#

refer to a specific place and person.

*acred eart ospital -mergenc# oom

' went to the emergenc# room.

The patient was ta(en to the operative suite.

7ett# *mith, .N.

ane Doe, *uperintendent

SUBCUT/SUBCU !bbreviated form for subcutaneous or

subcuticular. T#pe as dictated.

Do not use sub; or subQ.

*ubcut or subcu is acceptable.

TEMPORARY MRN "or all documents that come through without

demographic information and #ou are unable to

find, create a T$& document. &lease pendthese documents. 'nclude the name of patient

dictated on the pend note as well as the top of

the document, and an# other information

dictated b# the ph#sician.

1. &ress !9TI- to get into header.

6. &ress !9TI2 to get to visit grid.

). 8hile in the visit grid, arrow down to the patient number that islabeled @T@ and press spacebar when the empt# box next to the @T@

is highlighted.

4. &ress !9TIO to confirm the changes.

TIME "or on:the:hour expressions, it is preferable not

to add the colon and 55.

$ilitar# time, do not separate hours from

minutes with a colon.

*ee 7oo( of *t#le, pages 6L4:6LL, for time

referents.

M a.m. not M355 a.m.0

M31L a.m.

1)55 hours not 1)355 hours0

14



TIMES SYMBOL .X0 Use a lowercase . in expressions of area and

volume.

Use a lowercase . as a multiplication s#mbol.

Use a lower case x when indicating the number

of times something was done or period of time

) x 4 mm lesion

4 x 4 gau>e

46 x )M

The patient had pain x4 da#s.

VERBATIM T#pe verbatim, unless definitel# necessar# to

ma(e a correction.

Use critical thin(ing and discernment.

VERTEBRAL SPACES Use h#phen to express the space between two

vertebrae the intervertebral space0. 't is not

necessar# to repeat the same letter before the

second vertebra, but it ma# be transcribed if

dictated.

't is preferable to repeat the letter before each

numbered vertebra in a list.

*ee 7O*, third edition, pages )C6:)C).

%1:6 or %1:%6

9L:*1.

The lesion involves %4, %L and %=.

WOR- TYPES &lease refer to #our list of wor( t#pes specific

to #our facilit#.

'$&OT!NT3

8O<TF&- U9-* "O DO97-F03

'*TOF !ND &F*'%!93

$ust state '*TOF O" &-*-NT '99N-**

and D'!NO*T'% '$&-**'ON.

'f osteopath, must state

$U*%U9O*<-9-T!9 -!$.

1L



%ON*U9T!T'ON3

$ust state D'!NO*T'% '$&-**'ON.

D'*%!- *U$$!F3

$ust state "'N!9 D'!NO*'*.

1=



Appendix I: 2005 JCAHO ro!i"ited A""re#i$tionsBeginning January 1, 2004, JCA! o""er# a li#t o" #tandard a$$re%iation# that they re&uire tran#criptioni#t# not u#e' !ne

can con"u#e or (i#under#tand %ery ea#ily one a$$re%iation )ith another' TE !**+C+A A. !/T+!A + BETASATE.'

The "ollo)ing i# a li#t o" tho#e a$$re%iation# "or your re"erence' JCA! update# thi# li#t "re&uently' eScription #ugge#t# that you %i#itthe JCA! )e$#ite periodically to (aintain a current li#t "or your record#' i#it )))'3caho'org "or an updated li#t o" the#ea$$re%iation#'

1B

http://www.jcaho.org/





JCAHO Su%%ested option$l &do not use' $""re#i$tions

) ollo* t!e option$l +do not use+ list $s *ell,• All o" the JAC! re&uired A. optional do-not-u#e entrie# )ill $e tran#lated'

g"or (icrogra(5

Mi#ta6en "or (g (illigra(#5re#ulting in one thou#and-"old

do#ing o%erdo#e'

rite 7(cg7

'S'"or hal"-#trength or atina$$re%iation "or $edti(e5

Mi#ta6en "or either hal"-#trength or hour o" #leep at $edti(e5' &''S'

(i#ta6en "or e%ery hour' All canre#ult in a do#ing error'

rite out 7hal"-#trength7 or 7at$edti(e7

T'+''"or three ti(e# a )ee65

Mi#ta6en "or three ti(e# a day or t)ice )ee6ly re#ulting in an

o%erdo#e'

rite 78 ti(e# )ee6ly7

S'C' or S'9'"or #u$cutaneou#5

Mi#ta6en a# S "or #u$lingual, or 7:e%ery7'

rite 7Su$-97, 7#u$97, or 7#u$cutaneou#ly7

.;C

"or di#charge5+nterpreted a# di#continue

)hate%er (edication# "ollo)typically di#charge (ed#5'

rite 7di#charge7

c'c'"or cu$ic centi(eter5

Mi#ta6en "or < unit#5 )hen poorly)ritten'

rite 7(7 "or (illiliter#

A'S', A'.', A'<'atin a$$re%iation "or le"t,

right, or $oth ear#5

Mi#ta6en "or !S, !., and !<,etc'5'

rite= 7le"t ear,7 7right ear7 or 7$oth ear#7

1M