Medical Transcription Styles and Formatting
In addition to learning the unique language used by medical professionals, a medical transcriptionist must also be an expert on English grammar and spelling. As if that isn’t enough to remember, there are styles and formats that are unique to the medical field; not being familiar with these accepted guidelines can generate quality assurance issues for a transcriptionist and the medical records and impact patient safety.
Homonyms are difficult for many English speakers to master, but when they occur in medical language, it becomes even more tricky. For example: ileum and ilium. These are medical terms that refer to two different anatomical areas. In order to select the correct spelling, it’s necessary to be familiar with the anatomy and to look at the context in which the word occurs. Experienced transcriptionists develop a system of mnemonics that assist them in finding the correct spelling of a homonym.
The ilium is a bone in the pelvis; in lay terms, the hip bone. The ileum is part of the small intestine. An easy mnemonic is to remember that both hip and ilium have the letter “i”. After that, a transcriptionist needs to look at the context of the word use in order to apply the appropriate term and spelling.
Although not considered homonyms, there are terms that sound like something else entirely, resulting in a transcription error, usually by an inexperienced transcriptionist. “Below knee amputation” is frequently mistaken for “baloney amputation.” An experienced transcriptionist knows that there is no such thing as a “baloney amputation,” regardless of whether or not it sounds like that is what a dictator is saying! In medical transcription, these are referred to as “sounds-like” errors.
Abbreviations are very common in medical terminology. They allow physicians and other healthcare professionals to document records quickly. Unfortunately, there are many terms that can apply to one abbreviation, which can lead to mistakes. The Institute for Safe Medication Practices (ISMP) has published a list of terms and abbreviations that can be misread and advised that these be written or transcribed in specific ways in order to avoid confusion.
In medical terminology, the abbreviation OD or o.d. can be either right eye – or once daily. It’s essential for a medical transcriptionist to know that the ISMP recommends that neither abbreviation be used, that it be written out as “right eye” or “daily,” as appropriate.
Abbreviations may also be misread, as one letter closely resembles another, even in a typewritten report. The ISMP also recommends that the abbreviation “IU” (International Units) not be used, as it can be mistaken for “IV” (intravenous).
There are also guidelines governing abbreviations for measurements. The use of the abbreviation “cc” (cubic centimeters) is common, but not advised; documentation specialists are advised to use the abbreviation “mL” (milliliters) instead, as “cc” can be misread.
Documenting for accuracy and clarity
The core guidelines for medical transcription style and format are geared towards documenting the record with accuracy and clarity so that other healthcare professionals can easily find and read the information they need to make healthcare decisions, while feeling confident that the record is accurate insofar as the transcriptionist is able to interpret the dictator’s spoken word and intent.