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Guidelines for Transcription: General Surgery and Gastrointestinal System Dictation

by Ellen Drake, CMT, AHDI-FLinda Campbell, CMT, AHDI-F

The SUM Program General Surgery and Gastrointestinal System Transcription Unit was developed to meet the growing demand for quality training in medical transcription. It contains approximately 4-1/2 hours of authentic physician-dictated gastrointestinal (GI) system and general surgery reports, professionally edited to delete confidential information. The dictations in this unit provide comprehensive coverage of the entire GI tract from esophagus to rectum, as well as a variety of surgical reports that would be carried out by a general surgeon. Reports have been carefully selected for vocabulary density and include regional and foreign accents. The reports are first grouped by report type or content and within each group of reports sequenced in a graduated easy-to-complex fashion to maximize learning.

The General Surgery and Gastrointestinal System Transcription Unit will help prepare students for entry-level employment in an acute care setting and is well suited for self-starters in independent home study, for classroom instruction, and for on-the-job training in hospitals, clinics, transcription services, and medical group practices.

A total of 70 medical and surgical reports is offered. The nonoperative reports include history and physicals, consultations, and discharge summaries. Within each grouping, the reports are sequenced from easier to more difficult. The operative reports are grouped as follows: Vascular Access/Port Placement; Abdominal Wound Revision and Herniorrhaphy; Appendectomy; Cholecystectomy; Liver & Spleen Procedures; Head & Neck Surgery; Chest Wall Surgery, Breast Surgery, and Abdominoplasty; GI Upper and Lower Tract Surgery. Again, within each grouping, the reports are sequenced from easier to the more difficult; vocabulary density and difficulty level increases as well throughout the operative groupings themselves.

Accompanying each dictation is an accurate transcript with footnotes explaining edits and, where necessary, content. Ancillary material includes “Gut Reactions: Sorting Out IBS and IBD,” by John H. Dirckx, MD. Two articles written in 1989 and part of the first edition of the Gastrointestinal Transcription Unit are also included here because they are still relevant, informative, and interesting today: “A Surgeon’s View of Gastroenterology and Practice” by Thomas L. Largen, MD, and “Transcribing Gastroenterology Dictation” by Bron Taylor. A Quick-Reference List of General Surgery/Gastrointestinal Words and Phrases concludes the ancillary material.

A new feature is the inclusion of a series of audio soundalikes exercises, provided as individual clips (accessible when the instructor password is entered) for upload to a learning management platform and in four audio files (20 clips each for the first three exercises and 23 clips for the fourth). Both formats lend themselves to incorporation within an online learning management system for automatic grading. The soundalikes are provided at the beginning of the dictation but may be completed at any point in the course. Instead of a blank document opening, when the student clicks on a soundalike exercise, the text with a blank for the soundalike appears, and the student can transcribe the missing word (this is ideal for automatic grading). The transcript keys may be enabled if the instructor wants students to check their own work, or the student can e-mail the assignment to the instructor.

General Surgery/Gastrointestinal, The SUM Program Advanced Medical Transcription Unit, 2nd ed., 2011Health Professions Institute www.hpisum.com

Introduction to General Surgery/Gastrointestinal (GI) Transcription A standard English dictionary is paramount. Basic medical references recommended include

Dorland’s Medical Dictionary or Stedman’s Medical Dictionary, Vera Pyle’s Current Medical Terminology, a current edition of Saunders Pharmaceutical Word Book by Ellen and Randy Drake, and The Book of Style for Medical Transcription, third edition. Other useful references include H & P: A Nonphysician’s Guide to the Medical History and Physical Examination and Human Diseases, both by John H. Dirckx, M.D., and published by Health Professions Institute.

Transcription Technique

Meaningful Text. What is medical transcription? Medical transcription is an interesting skill that few people—even many of those who hire MTs or are MTs—truly understand. Many people think medical transcription is basically a physical skill, that is, typing or keyboarding. And that's part of it, a very small part. However, even the physical aspects encompass much more than hitting the correct keys on a keyboard because properly equipped MTs are also operating a foot pedal, which has a forward, fast forward, and reverse. Because they sit for long hours, MTs must be cognizant of their posture and their physical environment. But none of this comes close to describing what MTs actually do with their brains!

The transcriptionist listens to the spoken word, which can be marked by poor grammar and usage, disorganization, back-tracks, nonlanguage vocalizations, misspeaks, corrections, variable voice volume, and variable speed sometimes approaching Mach 2. The brain must interpret and translate these sounds, which pretty much correspond to a foreign language, into meaningful text (while it continues to control the fingers on the keyboard and the foot on the pedal and keep the body in an ergonomic position).

While interpreting the spoken word into meaningful text, the MT is also organizing, formatting, and paragraphing the text; applying grammar, punctuation, spelling, and style rules; correcting usage; and making sure that the finished report meets the specifications of the dictator or client. In addition, he or she is proofreading on-screen what has just been transcribed, while transcribing what was just heard and listening to the next set of sounds.

Essentially, the brain is performing multiple intellectual functions along with several physical functions. We can think of no other activity or skill that requires such intense mental processing, physical involvement, and concentrated focus of the participant (the MT).

Learning medical language is akin to learning a foreign language. Indeed, it contains many foreign words and phrases, primarily but not limited to expressions of Latin or Greek origin. Medical dictation also contains many abbreviations, brief forms, shortcuts, jargon, medical vernacular, and word coinages that are an integral part of the language of medicine. Because medical reports are dictated, their tone and style are often informal, even conversational.

Occasionally you may encounter a dictation that seems too challenging for you at the moment. Sometimes, especially with repetitive sections of a report like the review of systems, the physical examination, and the opening and closing sections of operative reports, it may take several MTs transcribing the same type of report by the same dictator before they can decipher all the words and phrases that are difficult to hear. Even good dictators may rush through routine sections of a report, and difficult dictators definitely become easier the more often you transcribe them. For that reason, we have purposely included multiple dictations by the same dictators for this unit.


Each time the physician dictates, different words will be clearer. On the job, practitioners often have access to templates or “normals” and “boiler-plate” paragraphs that help them decipher difficult dictators. As a student, you too can begin to create similar “normals” and “boiler-plate” paragraphs. As you identify difficult passages for a particular voice, make a note of it. When you hear that dictator again, dictating a similar passage, you should be able to decipher a bit more than you did on the previous attempt. Relistening to and retranscribing difficult dictation will also help you build skill in deciphering hard-to-understand phrasing.

The transcription of healthcare documents (medical or technical writing) differs in technique from the production of essays and manuscripts (formal writing). With the latter the writer often generates several draft copies before arriving at a finished polished document. There is no time in the production environment for an MT to accomplish the process described above in a stepwise fashion or to “polish” a document. In the workplace, it is simply not feasible or necessary for the production-oriented medical transcriptionist working in a fast-paced environment to attempt to convert a medical document into a piece of formal writing.

During your training, however, is the time to take advantage of all the luxuries you won’t have when you are on the job: the luxury of extensive research, not just for words themselves but background information so that you understand what is going on in the report; the luxury of transcribing a report more than once so that you can learn to identify repeated words and phrases and anticipate what’s coming next, building speed and accuracy through this process; the luxury of proofreading—multiple times, with and without the audio and by just reading the report aloud to yourself.

Your ultimate goal is to produce a first-time final copy without the use of a draft copy. The standard of quality you are striving for is that which you will produce in your future employment as a medical transcriptionist—a neat, accurate, and complete report that may be placed in the patient’s medical chart as a permanent record of healthcare. However, this is just the beginning. Keep your goal in mind but don’t get discouraged as you begin to transcribe. Do, however, strive to prepare a document that is free of wrong words and misspellings, that is, a report that is “chartable.” Make your goal “the right word, correctly spelled, in the right place.”

The first step. Before you begin transcribing, ascertain that your equipment is in proper working order. Assemble your reference books, gather your papers and supplies together, and isolate yourself from frequent interruptions.

It is important to read the introductory articles and to review the table of contents to gain an understanding of the types of reports you will be encountering. If you are given passwords to the transcript keys, briefly leaf through the transcripts so you will know how to set up the various formats.

Building a foundation. The reports in the General Surgery and Gastrointestinal System Transcription Unit are sequenced within each grouping of reports so that your terminology foundation builds as you advance to the next report as well as to the next group of reports. Plan to transcribe each report more than once, until you become thoroughly familiar with its terminology and competent in its transcription. Each transcript should be carefully proofread, with and without the audio, and corrections noted. After proofreading, you should transcribe (not copy-type) a final error-free copy, suitable for charting.


First, listen to each report, paying attention to the dictator’s tone and rhythm and any unusual speech characteristics or accent. Does the dictation flow or is it choppy? Does the dictator seem organized or does he or she stumble around and make a lot of corrections?

Pace yourself. First, listen to each report, paying attention to the dictator’s tone and rhythm and any unusual speech characteristics or accent. Does the dictation flow or is it choppy? Does the dictator seem organized or does he or she stumble around and make a lot of corrections? Make note of words you don’t know and look them up. Then, transcribe each report carefully, stopping as often as necessary to look up new and unfamiliar words for spelling and meaning.

The medical transcriptionist on the job encounters difficult terms as well. When presented with a questionable word or finding, the practitioner has several options: (1) Seek another transcriptionist’s opinion. (2) Refer to the patient’s chart, if available. (3) Contact the dictating physician to ask what was dictated. (4) Leave a blank in the report and flag it to the dictator’s attention. While you may not have access to these remedies as a student, you may want to confer with your instructor, acquire a mentor (the Association for Healthcare Documentation Integrity, AHDI, has a mentoring program for students), or consult with your classmates.

If you fail to locate a word in your reference materials, it could be that the word in question has an initial letter other than the sound you hear. For instance, the phonetic pronunciation of v sounds very much like that of f or b, the letter m may sound like n, and so on. Some letters share the same sound. The z sound you hear may actually be an x (xiphoid) and the k might be ch (ischemic). Medical terms that contain silent letters (gnathic, tachyarrhythmia) also present a challenge.

You can also use the Internet to conduct background research through sites like eMedicine.com or PubMed.com, perform context/phrase searches using Google, and find actual sample medical reports with similar content on medical student and transcription forum sites. Caution: If you use the Internet for research, you must be able to judge the accuracy of the content. See the article by Ellen Drake, “Searching the Wild, Wild, Web” in ePerspectives issue 57: May 2009, on the HPI Web site (http://www.hpisum.com).

As you gain experience utilizing available resources, you will become familiar with the techniques of determining soundalikes and efficient in locating the appropriate terms.

You may find that you are unable to understand a word the first time you encounter it, or you may not be able to find it in your references. When this is the case, leave a blank (or blanks) and continue with the transcription. The dictator may use the word in question a second time, enabling you to determine the appropriate term, or context clues may eventually help you decipher the term.

When you have finished a report, go back and listen to the dictation again while proofreading your transcript. Check the correctness of your transcript and attempt to fill in any blanks you left earlier. Transcriptionists often find they can decipher a difficult word after listening to it again at a later time.

If your instructor gives you the password for the transcript keys, be disciplined and do not consult the transcript keys until you have completed the reports to the best of your ability, using all available references. Comparing your transcripts with the transcript keys at the end of the transcription process will enable you to verify the accuracy of your work.

After you have compared your transcript to the transcript key or received a graded transcript back from your instructor, look up all the words you missed. Write them, correctly spelled, in a journal (an electronic journal is ideal for ease of searching) along with their definitions and two


or three sentences that illustrate the correct use of the term. Include the sentence from the report as well.

In addition, analyze the reason for your error. Was it simply inadequate research or did you do a lot of research but fail to find the term? Was your misspelling due to not hearing the word clearly or failure to apply rules of phonics? Did you use a soundalike and fail to verify the definition? There are many more questions you can ask yourself about why you misspelled a word, transcribed the wrong term, or left a blank. Once you determine why you made the mistake, you should develop a strategy for avoiding that kind of mistake in the future. If you need help in analyzing your errors or developing avoidance strategies, talk with your instructor.

Finally, if your transcript contained content errors (wrong words or seriously misspelled medical terms), transcribe the report again and follow the above processes until you have produced a report free of content errors.

Once you have corrected, accurate transcripts, you can use these as sample reports to help you decipher difficult dictators in the next section of reports that you transcribe.

Footnotes The GS/GI transcript keys have been prepared with the highest degree of accuracy. Because this is an advanced transcription unit, it is assumed that users will now be able to recognize certain types of edits that may have had footnotes in The SUM Program Beginning Medical Transcription Unit; thus, not every edit will have an explanatory footnote. Users should also be able to recognize when minor differences between their transcripts and the transcript keys are acceptable variations. Punctuation and grammatical editing changes generally are not footnoted; specific guidelines for these are addressed below. The addition of headings for consistency in format and expansion of abbreviations on first use are not footnoted. Reports requiring little or no editing have no footnotes. Generally speaking, ESL dictators may need more editing for grammar and syntax than dictators whose native language is English. In the transcripts, we have edited ESL dictators where we felt it appropriate, usually without footnotes to explain obvious edits for grammar and syntax. Footnotes are utilized to indicate medical dictation errors and to note editorial changes. When a dictation error occurs repeatedly within a report, it is usually footnoted only the first time it occurs.

Transcription Guidelines

Format and style. A variety of medical report formats and styles exist nationwide. The transcripts in this unit demonstrate several different acceptable formats but by no means all of them. In general, we have followed the ASTM standard for medical report formats as illustrated in the The Book of Style for Medical Transcription. The physician’s dictating style may determine the appropriate format, or a particular medical facility may mandate certain format standards. Thus, various report formats may vary from dictator to dictator, report to report, and setting to setting.

Speech recognition editing is having a major impact on style guidelines as well as the amount and kind of editing being done. It is not within the scope of these guidelines to address the differences between speech recognition editing and the preparation of transcribed medical reports. For simplicity’s sake, the transcript keys and these guidelines reflect the practices and standards used in traditional transcription.


We acknowledge that many stylistic factors determine proper editing, punctuation, and grammar, that our way is not the only way, and that respected reference materials vary and may even contradict one another and themselves. Additionally, the employer of the transcriptionist may mandate specific rules of style, grammar, and format, and in that case the transcriptionist should follow the employer’s requirements. As a general stylistic reference, we recommend The Book of Style for Medical Transcription. In addition, we offer the following specific recommendations.

Editing. The medical transcripts in this unit contain only minor editing changes. While the experienced medical transcriptionist, with a firm grasp of medical language and terminology and familiarity with the dictating physician’s preferences, may edit more extensively, we advise that the student transcribe the dictation verbatim (as dictated), making changes only to correct obvious dictation errors and to comply with standard style and usage guidelines.

The dictations have been carefully edited to remove any protected health information or other identifying data. The year has been removed from dates, but be aware that it is usually dictated and should be transcribed according to facility guidelines. In the operative reports the heading surgeon has been retained if dictated, but the surgeon’s name has been replaced with a brief silence. When other doctors’ names have been mentioned in the body of a report, the names were replaced with a brief silence if removing the entire reference wasn’t feasible. Model and serial numbers of implants have been altered as well, since these numbers can be used to track patients.

Not everything the physician dictates is meant to be transcribed. Dictators frequently dictate instructions related to formatting or requests to send copies, additional information to help identify a patient such as date of birth, asides, afterthoughts, and courtesy remarks. These types of comments often appear at the beginning or end of a report but may also appear in the body of the report. In addition, physicians may change what they want to say but fail to indicate that they are making a correction. When they do indicate a correction, even that is sometimes unclear; they may say “scratch that,” “I’m sorry,” or “let’s make that …” but still not make it clear what is to be changed. It is important to learn to distinguish between what should be transcribed and what should not. Many of the dictators in this unit self-edit, and even with a clear dictator, it may be challenging to sometimes decide what the dictator actually wants in the report.

Additionally, students and inexperienced transcriptionists tend to hear ums and uhs as words, often as conjunctions or prepositions. Just as every word is not meant to be transcribed, neither is every sound you hear a word. Be alert for meaningless sounds when you are trying to decipher unintelligible dictation. Furthermore, some dictators use the conjunction and in almost the same way as an um or uh. If a dictator consistently joins unrelated independent clauses together with and, it is permissible to separate the clauses into separate sentences.

In many circumstances several editing options are available, and the student’s transcripts will likely vary in style from the transcript keys provided, although there should be no variations in medical content.

Grammar and Usage. Medical transcriptionists are expected to correct inappropriate grammar, such as subject-verb agreement errors, use of the wrong part of speech, incorrect pronouns, and incorrect usage. Be careful not to edit grammar that is already correct.

Dictated: She will follow up with myself in 2 weeks. (reflexive pronoun)


Transcribed: She will follow up with me in 2 weeks. (objective pronoun)

Dictated: The patient was appraised of the risks and benefits of surgery. (appraise means to evaluate or place a value on)

Transcribed: The patient was apprised of the risks and benefits of surgery. (apprise means to make aware of)

Dictated & Transcribed: … fat was then removed in a crescentic pattern.What is meant: crescent-shaped patternDictated & Transcribed: Once we had this complete, we assured that we had adequately dissected the mesentery free.

Note: Although ensured is more common in the above context, assure, ensure, and insure all mean “to make secure or certain.” Although ensure and insure are generally interchangeable, insure is now widely used in American English in the commercial sense of “to guarantee persons or property against risk.” Assure is also used with reference to a person in the sense of “to set the mind at rest”: We assured the patient that the tumor was benign. [Source: The American Heritage Dictionary of the English Language.]

Dictated: We aspirated the irrigation … (irrigation is the act of irrigant)Transcribed: We aspirated the irrigant … (irrigant is the fluid used to irrigate)

Dictated: The umbilicus was then dissected free by placing 2 single skin hooks and using a #10 blade used to incise the skin along with sharp scissor.

Transcribed: The umbilicus was then dissected free by placing 2 single skin hooks and using a #10 blade used to incise the skin along with sharp scissors.

Note: Forceps and scissors, though singular in nature, are regarded as plurals; they take a plural verb unless the subject is pair. (“A pair of scissors was used.” “Scissors were used.)

Dictated: There were no adenopathy appreciated.Transcribed: There was no adenopathy appreciated.

(Adenopathy is the subject of the verb was.)

Dictated: There was no nodules palpable in the area other than the liver proper.Transcribed: There were no nodules palpable in the area other than the liver proper.

[The subject is nodules.]

Tip: Whenever a sentence starts with there, be alert for subject-verb errors. Because the subject follows the verb and the mind tends to race ahead of the tongue, this is where a majority of subject-verb agreement errors occurs.

Dictated: The carotid sheath containing the carotid artery, internal jugular, and vagus nerve were then exposed and retracted.

Transcribed: The carotid sheath containing the carotid artery, internal jugular, and vagus nerve was then exposed and retracted. [The subject is sheath.]


Note: Words, phrases, and clauses separating the subject from the verb are frequent causes for subject-verb agreement errors. Read the sentence without the intervening expression and choose the verb accordingly. Expressions such as with, as well as, in addition to, including, etc., frequently follow the subject in medical dictation but do not change the number of the subject or the verb, although objects of prepositions that intervene between a collective noun and the verb may affect the verb.

Dictated: It was felt that due to her steroid dependence and her diabetes mellitus that she was at great risk for fatal biliary tract sepsis.

Transcribed: It was felt that due to her steroid dependence and her diabetes mellitus she was at great risk for fatal biliary tract sepsis.

orTranscribed: It was felt, due to her steroid dependence and her diabetes mellitus, that she

was at great risk for fatal biliary tract sepsis.

Syntax or sentence structure. Where warranted, the transcriptionist may add conjunctions (and, or, but), prepositions (of, to, with), articles (a, an, the), pronouns (it, she, her, he, him), and verbs (including helping verbs) to complete a sentence. Such editing may be considered superfluous in a strict verbatim environment, and the MT should avoid altering the dictator’s style. It should also be noted that certain parts of a report (the physical exam for example) may be defined by clipped sentences, phrases, and single words. However, if full sentences are being dictated and a heading needs to be added, add the heading and retain the complete sentence to maintain the dictator’s style. Do not turn a complete sentence into an incomplete sentence by lopping off the subject and making it the heading.

Dictated: No tenderness present over chest.Transcribed: No tenderness is present over the chest.

Dictated: 25-year-old male presents to the office for routine examination.Transcribed: This 25-year-old male presents to the office for routine examination.

Dictated: The heart has a regular rate and rhythm. (on a physical examination)Transcribed: Heart: The heart has a regular rate and rhythm.

notHeart: Has a regular rate and rhythm. orHeart: Regular rate and rhythm.

Misplaced modifiers/awkward wording. With the trend toward verbatim transcription and the widespread adoption of speech recognition, misplaced modifiers and awkward phrasing have become less troublesome to many and are rarely edited. However, when a sentence is extremely awkward, the meaning is unclear, or it provokes unintended humor, judicious editing is recommended.

Dictated: CT evaluation on several occasions of her abdomen revealed …


Transcribed: (As dictated or) CT evaluation of her abdomen on several occasions …

Dictated: Once it was freed completely, it appeared to be a lipoma with a nodule which was felt to be later fat necrosis.

Transcribed: (As dictated or) Once it was freed completely, it appeared to be a lipoma with a nodule which later was felt to be fat necrosis.

From a colonoscopy report: Dictated: No source of bleeding was seen until I was coming out and was sitting in the

transverse colon when she got very upset …Transcribed: No source of bleeding was seen until the scope was coming out and was

sitting in the transverse colon when she got very upset …

Dictated: Pneumoperitoneum was allowed to develop, and evaluation with the camera revealed no evidence of harm to our abdominal contents.

Transcribed: Pneumoperitoneum was allowed to develop, and evaluation with the camera revealed no evidence of harm to abdominal contents.

Dictated: Dr. _____ performed the cystocele first, which is dictated under a separate note.

Transcribed: Dr. _____ performed the cystocele repair first, which is dictated under a separate note.

Redundancies. When an exact or near-exact redundancy is dictated, edit out the redundant statement. However, be careful not to remove text intended for emphasis or change the dictator’s style.

Dictated: The patient was brought to the operating room where, after the institution of general endotracheal anesthesia, the abdomen was prepped and sterilely draped in the customary fashion. Once I saw the abnormal appendix at exploration, he was given IV for infection prophylaxis. The abdomen was prepped and sterilely draped in the customary fashion.

Transcribed: The patient was brought to the operating room where, after the institution of general endotracheal anesthesia, the abdomen was prepped and sterilely draped in the customary fashion. Once I saw the abnormal appendix at exploration, he was given IV for infection prophylaxis.

Paragraphing. Transcribe paragraphs as dictated unless paragraphing would alter medical meaning or continuity. Paragraphing may be added where appropriate to break up long reports, to delineate headings, and to separate the findings from the details of the procedure in an operative report. In a long operative report, a good place to add paragraphs is when the dictator says something like “Attention was then turned,” or “Next, …”

Tense. As a rule, all parts of a History and Physical and Consultations, except for ongoing symptoms and the physical exam, are generally dictated in past tense; the findings on a physical exam are often dictated in the present tense. Discharge Summaries and Operative Reports are


generally dictated in the past tense, although some surgeons dictate in the present tense. However, it is possible to correctly use every tense within a single paragraph. Some physicians dictate in the present tense, some in the past, and some switch back and forth. While some dictators expect the transcriptionist to edit to the appropriate tense, other dictators insist that the report be transcribed as dictated. When the dictator’s preference is not known, the transcriptionist may transcribe as dictated. Editing tense is tricky, and the transcriptionist should be very certain that an edit is needed before making one.

Headings. The transcriptionist may add headings and subheadings as appropriate. If a physician dictates the singular form Diagnosis when more than one diagnosis is provided, the transcriptionist may transcribe either Diagnosis or Diagnoses.

The transcriptionist should be alert for important headings that are not dictated but are a vital part of the report. These include the Final or Discharge Diagnosis in a Discharge Summary; the Diagnosis or Impression in a History and Physical and a Consultation; and the Preoperative and Postoperative Diagnoses and Title of Operation in an Operative Report. If any of these headings are not dictated, the transcriptionist should supply them as appropriate or flag the report to the attention of the dictator.

Abbreviations and brief forms should be expanded in headings and subheadings.

Report Format. There are many acceptable formats for the setup of medical and surgical reports. In addition, there are alternative acceptable forms for the same sentence, depending on whether the format calls for a narrative such as might be contained in a discharge summary, subheadings such as in a consult or office note, or main headings as in the physical examination portion of an H&P. The following examples represent just a few of such variations in format.

Dictated: Extremities unremarkable.

Transcribed: (as dictated or) The extremities are unremarkable. (Narrative paragraph format.)

Transcribed: EXTREMITIES: Unremarkable.(Formal Physical Examination with separate paragraphs for each subheading.)

Transcribed: EXTREMITIES: The extremities are unremarkable.(Formal Physical Examination with separate paragraphs for each subheading.)

Note: If full sentences are dictated and headings need to be added, add the heading and transcribe the full sentence. Don’t lop off the subject of the sentence as a heading and start the text with a verb or phrase.

Diagnoses and Lists. When the dictator says same for a discharge diagnosis or postoperative diagnosis, copy and paste the diagnosis to which he is referring; do not transcribe same. Dictators may or may not dictate numbers; however, diagnoses usually should be transcribed in a numbered vertical format if more than one diagnosis is dictated. Medications may be transcribed


as a vertical list or in a horizontal narrative style. On the job, facility specifications would dictate how lists should be transcribed, including any special formatting for diagnoses.

Abbreviations, Brief Forms, Medical Slang, and SymbolsAbbreviations are frequently dictated in medical reports and are an integral part of the

language of medicine. Many professional transcriptionists readily utilize abbreviations when dictated, and in some instances, the translation of abbreviations may cause confusion rather than achieve clarity. For example, VDRL is readily recognized as a laboratory test for syphilis but would be obscure if translated Venereal Disease Research Laboratory.

Many professional medical transcriptionists prefer to spell out all abbreviations and brief forms when dictated. Their rationale is that abbreviations obscure the clarity of the medical report and make it imprecise. On the other hand, many other professional transcriptionists readily utilize abbreviations when dictated.

Except for the abbreviations specified below that need not be translated, Health Professions Institute has, in all of its dictation units, expanded most abbreviations on first use within a report to ensure that the students are actually hearing the abbreviations correctly. One consonant can often sound like another—p, b, t, and d are often confused with each other, as are p and v, b and v, m and n, s and f, even n with the word and (&). Unless required to expand abbreviations, students may not realize they’re transcribing the wrong letters. Furthermore, requiring students to expand abbreviations ensures that they will be able to do so if required to on the job.

Abbreviations for laboratory tests (CBC, PT, TSH, etc.), electrodiagnostic tests (EMG, EKG, EEG, etc.), imaging procedures (CT, MRI, PET, SPECT, etc.), and metric units of measure (cm, mm, mL) are rarely expanded and sometimes appear even in diagnoses. Other common abbreviations, easily recognized by anyone with a medical background (and some lay persons) may not need to be expanded as well (abbreviations like HEENT, CPR, AIDS, HIV, for example). Department and unit abbreviations (OR, ED, ER, ICU, PACU, NICU) need not be expanded. Of course, “easily recognized” can be said to be in the eye of the beholder, so if in doubt, ask for specific guidance from your instructor or, on the job, your supervisor or quality assurance department.

The ISMP Error-Prone Abbreviations List. See the ISMP Web site (http://www.ismp.org/) or The Book of Style for Medical Transcription, 3rd edition, for a complete listing of the ISMP (Institute of Safe Medical Practices) list of error-prone abbreviations. In practice, the list has been controversial.

The Joint Commission, the organization that accredits hospitals, nursing homes, and other healthcare facilities, recognizes the value of the ISMP list; however, it has chosen to incorporate only a few of the abbreviations on its official “Do Not Use” list. The abbreviations on the “Do Not Use” list are as follows:

U write out unitIU write out International Unitsq.d. (upper and lowercase, with and without periods) translate as dailyq.o.d. (upper and lowercase, with and without periods) translate as every other dayMS translate appropriately as morphine sulfate or magnesium sulfateMSO4 translate appropriately as morphine sulfate or magnesium sulfate


http://www.ismp.org/

MgSO4 translate appropriately as morphine sulfate or magnesium sulfate

The Joint Commission list also requires adding a leading zero to doses of less than 1 (0.5) and omitting a trailing zero from whole unit doses (50 IU) because in both cases the decimal point can be missed. Additional abbreviations for possible consideration on the JC’s official “Do Not Use” list include abbreviated drug names, apothecary units, cc which should be written as mL, and the symbol for micrograms, which can be abbreviated mcg.

In these transcript keys, we have generally followed the ISMP list, rather than the Joint Commission’s official “Do Not Use” list because it is the ISMP list that is in the The Book of Style for Medical Transcription and most easily accessible by the users of this program. However, it should also be noted that the Joint Commission is emphatic that it is not the transcriptionist’s responsibility to edit error-prone abbreviations.

The primary responsibility for compliance rests with the author of the documentation. “Author,” in this context, includes a person who dictates documentation to be transcribed. We would consider it inappropriate for a transcriptionist to interpret or speculate on the intended meaning of any dictation that is not clear. If a “do not use” term is used in the dictation and the dictation is clear, that term should be transcribed as spoken; not translated or edited into its presumed meaning. If the dictation is not clear, then there must be a mechanism by which the originator can clarify it.

Joint Commission Patient Safety Goals, New, 1/07

As with most style issues, the employer or client will no doubt have specific requirements regarding the use of error-prone abbreviations, may even have adopted its own list, and will have policies regarding whether the transcriptionist should edit error-prone abbreviations.

Abbreviations, Brief Forms, Slang, and Symbols in the GS/GI UnitWhen dictated, abbreviations may be transcribed in the body of a report and at the beginning

of a sentence, if their meaning is clearly understood. Abbreviations with more than one translation should be expanded if the correct expansion can be determined.

JP drain was inserted and will be removed when appropriate.EEA stapling device was utilized.The GI tract was unremarkable.PAST MEDICAL HISTORY: Recurrent UTIs.

Dictated: H&H 13.5/39.5.Transcribed: Hemoglobin 13.5 and hematocrit 39.5.

Dictated: D/C or DC’d.Transcribe: Discharge(d) or discontinue(d), whichever fits the context.

If the dictator abbreviates the title of a major heading within a report, the transcriptionist should translate the abbreviation.


Dictated: GU:Transcribed: GENITOURINARY:

The first time an uncommon abbreviation is used within a report, the transcriptionist should translate it and put the abbreviation within parentheses following the translation.

Dictated: Cultures grew MRSA from his gallbladder. (Note: MRSA is often pronounced “mersa.”)

Transcribed: Cultures grew methicillin-resistant Staphylococcus aureus from his gallbladder.

Dictated: He was started on subcutaneous Lovenox for DVT prophylaxis.Transcribed: He was started on subcutaneous Lovenox for deep venous thrombosis (DVT)

prophylaxis.

Dictated: The patient underwent MRCP.Transcribed: The patient underwent magnetic resonance cholangiopancreatography

(MRCP).

Disease entity abbreviations should be expanded in diagnoses and the abbreviation enclosed in parentheses.

POSTOPERATIVE DIAGNOSISIdiopathic thrombocytopenic purpura (ITP).

SECONDARY DIAGNOSESGastroesophageal reflux disease (GERD).

In instances where translation of the abbreviation may confuse rather than clarify, the abbreviation should be retained.

PDS subcuticular sutureILS stapler

Brief forms and slang. Brief forms can be confused with medical slang. Brief forms are shortened forms of legitimate words that can be documented in a reputable dictionary. A good rule to remember is, “When in doubt, spell it out.” A slang term is either not listed in reputable references or if listed is designated slang. Slang terms are often taken from the middle or ends of medical terms rather than the beginning. Avoid the use of slang terms and phrases except when essential to the report, when editing would result in excessive wordiness or restructuring, or when their meaning cannot be determined with certainty.

Brief Form Slangamp (ampule)

lab (laboratory) alk phos (alkaline phosphatase)


exam (examination) crit (hematocrit)D/C, DC’d (discharge, discontinue; discharged, discontinued)epi (epinephrine)lap (laparotomy, laparoscopy, laparoscopic)lytes (electrolytes)mills (milliliters)path (pathology)pect (pectoralis)tic (diverticulum)

Symbols. The symbol x may be used to represent the word times. It is also used to represent by in measurements. Do not use x for times when it means for.

sponge and needle counts reported as correct x2DRAINS: Jackson-Pratt (JP) x4.3 x 5 cmdiarrhea and constipation for 10 days (not, x10 days or times 10 days)

The percent symbol (%) should be used with numerals; in a range, the symbol should be repeated with each value in a range.

0.25% Marcaine (dictated as “quarter percent Marcaine”)0.5% Marcaine (dictated as “half percent Marcaine”)10% to 20%

The degree symbol º does not transmit well electronically, so it is recommended that degrees be spelled out in medical reports. If the temperature scale (Fahrenheit, Celsius, centigrade) is also dictated, write it out as well, changing centigrade to the preferred metric scale, Celsius.

In medical reports where the degree symbol is used, the abbreviation F is used for Fahrenheit and C for Celsius and centigrade. Do not insert a space after the degree symbol or a period after the abbreviation for the scale.

37ºC 37 degrees Celsius98.6ºF 98.6 degrees Fahrenheit

The virgule or slash (/) mark means equivalence or duality. It is sometimes misused by dictators when a simple comma or semicolon is all that is needed.

Dictated:OPERATIONExploratory laparoscopy, cholecystectomy with cholangiograms/difficult dissection.

Transcribed:OPERATIONExploratory laparoscopy, cholecystectomy with cholangiograms; difficult dissection.


Numbers

At Beginning of Sentence. Avoid beginning a sentence with a numeral. Either write out the number or alter the beginning of the sentence.

Dictated: 2 mL of Xylocaine was given.Transcribed: Xylocaine 2 mL was given.

Dictated: 45-year-old black maleTranscribed: A 45-year-old black male or

This is a 45-year-old black male orThis 45-year-old black male (if verb follows)

Dictated: … then the abdomen was reclosed. #1 Prolene was used in a running fashion, starting at both ends and meeting in the center.

Transcribed: … then the abdomen was reclosed. A #1 Prolene was used in a running fashion, starting at both ends and meeting in the center.

orTranscribed: … then the abdomen was reclosed; #1 Prolene was used in a running

fashion, starting at both ends and meeting in the center.or

Transcribed: … then the abdomen was reclosed. No. 1 Prolene was used in a running fashion, starting at both ends and meeting in the center.

Dictated: Twenty milliliters of 0.5% Marcaine with epinephrine was used as field block.

Transcribed: Then, 20 mL of 0.5% Marcaine with epinephrine was used as a field block.

Note: If the preceding sentence is related, you can use a semicolon instead of a period and transcribe as dictated.

When a quantity and unit of measure immediately follow a heading such as estimated blood loss at the beginning of an operative report, however, transcribe the numerals.

Dictated: Estimated blood loss 10 mL.Transcribed: ESTIMATED BLOOD LOSS

10 mL.

Fractions. Fractions should be transcribed as decimals when they are used with metricunits of measure, and decimals should be converted to fractions when they are used with standard units of measure. English fractions may be spelled out or transcribed as numbers, depending on style preferences; quarter-inch Penrose drain or 1/4-inch Penrose drain are both acceptable. Do not allow autocorrect to convert English fractions (1/4, 1/2, 3/4) into single-digit numbers (¼, ½, ¾) as these characters may not transfer correctly to another computer system.


0.25 cm 1/4 inch 3.5 mL

Note: Dictators almost always dictate metric fractions the same way they dictate English fractions: one-half is 0.5 in metric, 1/2 in English; one-quarter is 0.25 in metric, 1/4 in English.

Metric numbers less than one should be preceded with a zero and a decimal point (0.5) to avoid the decimal being lost and the number interpreted as a whole number rather than a fraction, whether or not the zero was dictated. If the physician dictates a whole number with a decimal point and a zero, retain the decimal and the zero if the value refers to a laboratory test result or dimensions or volume in surgery and pathology. If the value refers to a drug dose, do not place a decimal and a zero after the whole number.

0.5 mm in diameter 3 cm in length but 3 inches

Adjacent Numbers. Spell out one of the numbers to avoid the juxtaposition of two numbers.

three 2-0 Ethibond suturesfigure-of-eight 0 Maxon or 0 Maxon figure-of-8 suture

Inexact Numbers. In general, spell out inexact values and the unit of measure. However, if the article a is used to represent the number 1, transcribe the numeral.

Dictated & Transcribed: several centimeters

Dictated & Transcribed: I was able to clear away a centimeter plus in diameter circumferentially around the opening.

Dictated: It was approximately a centimeter in diameter or less.Transcribed: It was approximately 1 cm in diameter or less.

Dictated: The hole itself was approximately a centimeter and a half or so in diameter.Transcribed: The hole itself was approximately 1.5 cm or so in diameter.

Dictated: … we had been in the operating room already an hour and a half….Transcribed: … we had been in the operating room already 1-1/2 hours …

Plural Numbers. Do not add an apostrophe when pluralizing multi-digit numbers; do add an apostrophe when making single-digit numbers plural.

100s 4 x 4’s


Suture, blade, and drain sizes. A number sign may or may not be dictated. As a general rule, transcribe as dictated. When the size is a whole number, the number sign may be added for clarity. A size zero suture may be dictated and transcribed as 0 or 1-0. Multiples of 0 should be expressed with a number and hyphen before the zero.

2-0 Dexon suture #1 Tevdek suture #10 Blake drain

EponymsEponyms are capitalized, but the noun they modify is not. Derivatives of eponyms are not

capitalized. The use of the apostrophe plus s (’s) to form a possessive eponym is acceptable when dictated. When the eponym is used alone without the accompanying noun, the possessive is retained. The reports in this unit were transcribed as dictated, and the ’s was used when the physician dictated the possessive form.

Barrett esophagus or Barrett’s esophagusCooper ligament or Cooper’s ligamentCrohn disease or Crohn’s diseaselactated Ringer’sMcBurney point or McBurney’s pointMeckel diverticulum or Meckel’s diverticulum or Meckel’sScarpa fascia or Scarpa’s fascia Scarpa’s was reapproximated …spigelian herniasubscarpallyTrendelenburg position

PunctuationStandard punctuation is followed in these transcripts. Where the physician dictates

punctuation marks, you should transcribe as dictated, unless the punctuation is incorrect or results in an error in meaning. Punctuation marks may be added or changed to clarify meaning and assist in reading.

Comma. There are two schools of thought on comma usage. The traditional approach requires frequent use of commas for clarity. Contemporary usage avoids heavy use of commas in order to simplify and unclutter the written language.

Although either style is acceptable, contemporary usage (demonstrated in these transcripts) is more compatible with medical and technical writing. No matter which style you use, strive for consistency in punctuation within each report that you transcribe.

Hyphen. The trend in contemporary usage is to avoid the use of hyphens when they are not required for clarity. The use of hyphens with metric abbreviations is discouraged by the S.I. Committee and is no longer recommended by The Book of Style for Medical Transcription, 3rd edition. The hyphen is retained, however, with nonmetric units of measure.

7 cm mass


3 cm incision1-inch scar18-gauge needle

Hyphens are still used in other compound nouns, verbs, and adjectives, however. Check with a reputable reference to determine whether a compound noun is one word, two words, or hyphenated. Here are a few examples from the dictations.

a several-month historya side-to-side fashionA suture ligature was placed. (adjective modifying a noun)a xiphoid-to-umbilicus incisionabdominal-perineal resection (compound adjective)double-clamp technique (compound adjective modifying a noun)Each of these was double-clamped … (compound verb)extra-large Marlex plugshigh-grade dysplasialeft-sided opacitylow-lying rectal cancerlow-residue dietnonhealing, chronic-draining area (compound adjective containing present participle) The artery underwent suture-ligation … (compound noun)The artery was suture-ligated … (compound verb) but through-and-through anterior fascial stays of 2-0 Proleneultrasound-confirmed communicating right hydrocele

(compound adjective containing past participle)

Note: In two examples above (a side-to-side fashion and a xiphoid-to-umbilicus incision), you cannot replace the word to with a hyphen. Hyphens replace the word to in number ranges, not words. The expression is not a range; it indicates a directional relationship from one structure to another structure.

Prefixes and Suffixes. Most common prefixes (pre-, re-, non-, un-, etc.) are not followed by a hyphen unless they precede a proper noun, an abbreviation, or a phrase. Hyphens are no longer used in common words like reexamine and reexplored. Generally, a hyphen is added only when there are three vowels (salpingo-oophorectomy) or when needed for pronunciation (de- emphasize) or meaning (re-treat versus retreat). The list of prefixes that are almost always followed by a hyphen is short (self-, ex-, all-, half-, and perhaps a couple of others). Similarly, suffixes are not preceded by a hyphen with rare exception, -like and -type being two of the most common in medical reports.


A hyphen is sometimes added for clarity, so that a reader doesn’t stumble over the meaning or pronunciation of a term.

Postoperatively he defervesced for several days; however, he began to re-spike fevers.The patient was re-prepped and draped.The Port-A-Cath had been pre-flushed with saline.

The prefix post is generally not hyphenated. When used as an adjective before a noun, post is connected to the root word without a hyphen. When it functions as a preposition (meaning after), it stands alone.

The postoperative assessment was negative.The patient is status post cholecystectomy.The patient was taken to the postanesthesia care unit.

When like or most appears as a suffix, it is attached to the root word without a hyphen, unless the root word is multisyllabic or failure to hyphenate would affect clarity.

sphincter-like seizure-likeuppermost lateral-most

The use of hyphens with mid varies. The prefix mid may stand alone as an adjective (mid and left chest) or combine with a root word without a hyphen (midchest, midline, midlateral). Mid may be hyphenated if used with a phrase or if it precedes a word that begins with another prefix (mid-epigastric region).

Like most prefixes, non- is not hyphenated (nonobstructed) except when it precedes an eponym (non-Hodgkin), an abbreviation (non-HIV), or a phrase (non-insulin-dependent), although with the latter you may see noninsulin-dependent. Many dictators use non- before words where un- would be a better choice, as with nonresectable, but we do not generally edit this usage.

Single Letters. A hyphen is not needed to connect a single letter and noun combination such as J tube, J wire, and T tube; however, a hyphen is used to join a single letter and noun when they function as a compound adjective (Y-shaped incision, T-tube cholangiogram).

Ethnicity. Compound designations of Americans identified by ethnicity, race, or nationality are no longer hyphenated, either as nouns or adjectives.

Japanese American maleMexican American female

Colon/Capitalization. Capitalize the first word following a colon in a heading or subheading.

HEART: The heart sounds are strong on auscultation.


Period. A period should be placed at the end of each line following a heading, even if it does not represent a complete sentence. The period indicates that the line is complete and nothing has been omitted.

PREOPERATIVE DIAGNOSISUmbilical hernia, incarcerated.

POSTOPERATIVE DIAGNOSISUmbilical hernia, incarcerated.

PROCEDURE PERFORMEDRepair of incarcerated umbilical hernia.

Question Mark. When a physician dictates a question mark, it indicates that a finding or diagnosis is uncertain. Transcribe the question mark; do not spell out the words. Note that there is no space between the question mark and the word following it. If the question mark follows the finding, it can be placed in parentheses for clarity.

Dictated: PREOPERATIVE DIAGNOSISCarcinoma of the liver; query metastatic, query primary.

Transcribed: PREOPERATIVE DIAGNOSISCarcinoma of the liver; ?metastatic, ?primary.

Dictated:PREOPERATIVE DIAGNOSISQuestion mark axillary mass, left side.

Transcribed:PREOPERATIVE DIAGNOSIS?Axillary mass, left side.

Dictated: There also appeared to be a possible ruptured ovarian cyst question mark, but that was not certain.

Transcribed: There also appeared to be a possible ruptured ovarian cyst(?), but that was not certain.

Quotation Marks. Quotation marks should not be used in a medical report unless the physician is directly quoting the patient or dictates quotation marks.

The 12 mm port was closed under direct vision using the Endo Close device and 0 Vicryl, closing the “endoabdominal fascia.” [quotation marks dictated]


TrademarksTrademarked and registered terms (devices and drugs) are generally transcribed with an

initial capital letter. Mixed capitalization may be used, if known. However, manufacturers will often show their trademarks in all capital letters, a marketing technique to make the name stand out in advertisements and press releases. This practice is inappropriate for medical reports as it draws undue attention to the term. As with eponyms, derivatives of trademarked terms are not capitalized (bovied, steri-stripped). With few exceptions, common nouns (blade, suture, device, stapler, etc.) used with trademarked terms are not part of the trademark and are not capitalized.

Some terms may sound like they’re trademarks but aren’t. You cannot trust Google results for proper capitalization, style, or spelling of trademarked terms, so it’s always a good idea to confirm a trademarked term, either in a reputable reference or on the manufacturer’s Web site.

Angelchik ring prosthesis Bovie cautery, but boviedcollodion dressingEndo Catch bagEndoloop sutureEpifoamGore-Tex meshHarmonic Scalpel (Scalpel is part of the trademark)Medipore tapePerFix Marlex plugPolysorb suturePort-A-CathProTack fixation deviceSavary esophageal dilatorsqueegied (from Mr. Squeegy)Steri-Strips, but steri-strippedTegaderm dressingVentralex sheet

Tip: Newer drugs and trademarked devices often have a dedicated Web page, and you can put the term correctly spelled into the URL box followed by .com and hit enter to get more information about a drug or device.

Units of Measure It is customary to abbreviate metric measurements when associated with a numeral in medical reports. When indefinite values are dictated, spell out both the value and the unit of measure. Abbreviations for metric measurements contain no periods and are in the same form for both singular and plural usage. For example, cm is the abbreviation for both centimeter and centimeters. Standard English units of measure contain so few letters that they are usually spelled out.

mg (milligrams) inch


mmHg (millimeters of mercury) footseveral centimeters

Metric measurements in this transcription unit follow the recommendations of the SI system (Système International d’Unites); for example, cm (centimeters), mL (milliliters), and g (gram).

In a series of metric measurements, do not repeat the unit of measure unless it is different for the different values or its absence would confuse the reader.

Dictated: 3.3 cm x 1 x 4Transcribed: 3.3 x 1 x 4 cm But: 2.5 mm x 2 cm

Use a singular form of a verb with units of measure.

Approximately 10 mL of fluid was aspirated from the abdominal cavity.

Vernacular/MedspeakDoctors frequently speak in a clipped, abbreviated manner. There’s a fine line between slang

and colloquial and what is acceptable or not. It’s often quite difficult to define. For example, they may use only the first word of an adjective-noun phrase. In addition, doctors are fond of coining words, that is, making up new words. Many of these coined words cannot be verified. After making sure that you are hearing the word correctly and that no similar word with the intended meaning exists, you may spell a coined word using the techniques you learned in your medical language course. When uncertain about the spelling or whether you’re hearing the term correctly, it’s a good idea to flag.

Dictated & Transcribed: Labs were stable.What is meant: Laboratory test results were stable.

Dictated & Transcribed: The area was checked for bleeders and any were cauterized with bipolar.What is meant: bipolar cautery

Dictated & Transcribed: This [lesion] was electrocauterized and the specimen sent to Pathology for routine fixation and study.What is meant: The lesion was removed with electrocautery.

Dictated & Transcribed: … 3-0 Vicryl intracutaneous interrupteds were used …What is meant: interrupted sutures

Dictated & Transcribed: Cricomyotomy.What is meant: Cricopharyngeal myotomy.


Dictated & Transcribed: de-serosalizationWhat is meant: the serosa was torn or taken off

(the hyphen was added for ease of pronunciation)

Dictated & Transcribed: A total of 300 mL of lipoaspirate was suctioned.What is meant: the material aspirated by liposuction

Dictated & Transcribed: Nerve integrity endotracheal tube was placed.What is meant: Nerve integrity monitoring endotracheal tube …

Dictated & Transcribed: Bovie electrocautery was used to carry the dissection down to Scarpa fascia and then angled upward subscarpally.

What is meant: below Scarpa’s fascia

Word Forms

Alternative spellings. Some words have more than one acceptable spelling, and the preferred spelling may vary from reference to reference.

curet, curettelong-standing, longstandingmammaplasty, mammoplasty

Note: Although mammaplasty appears to be the preferred spelling in medical dictionaries and in PubMed citations, mammoplasty follows the more traditional construction (mammogram) with its use of the combining vowel o.

Combined forms. Physicians frequently dictate combined forms. It is acceptable to use either the combined form or the standard (often hyphenated) form when it is uncertain which is dictated.

femoral-popliteal or femoropoplitealinferior-lateral or inferolateraltracheal-bronchial or tracheobronchial

Plurals. Generally, medical words derived from Latin or Greek are pluralized according to guidelines in the recommended references. However, some physicians prefer to pluralize Latin terms in the same way that English words are pluralized. Transcribe as dictated unless incorrect.

fistulas or fistulae lumens or lumina cannulas or cannulae

Tricky Spellings. Beware of words spelled differently when their form changes.

inflamed, inflammatory fascia lata, tensor fasciae latae


Summing It UpThis versatile training unit was developed to meet the needs of all transcription students.

Whether your method is by self-study or formal instruction, whether you are a novice or an experienced generalist with a desire to assess your competency, we recognize your worthwhile goals and encourage you in your endeavors.


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