Medical Transcription Rules for Preparing Reports

There are certain basic rules that must be followed by all the professionals in the medical transcription industry. The American Association for Medical Transcription (AAMT) style guide is very popular and is in use around the globe. The style guide guides the medical transcription professional in all the different aspects of transcription that includes topics spacing during typing of text,numbering/ numerical typing, punctuation, hyphenation, drug terminology, capitalization rules, measurements, symbols to be used, classification rules, proofreading and more.

Let me now mention about some of the important rules that must be followed during the transcription/preparation of various medical reports.

• While writing the history of the present illness it is preferred to use the present tense or a mixed tense.
• Use past tense only while writing about a past medical history.
• Type all allergies in capital
• The Assessment/Diagnosis/Impression report must be entirely in capital letters without abbreviations for any medical terminology. However measurement units can be abbreviated.
• Use past tense in discharge summaries
• If no allergies found, type "No known drug allergies."
• All major physical examination reports to be in the present tense
• Use the correct verb tense to communicate the appropriate time of the action.(even if the dictation is wrongly tensed)
• The title "Doctor" is to be written in full
• Capitalize brand name medications. One must not capitalize generic medications.
• Use Latin drug abbreviations.
• Arabic numerals must be use when referring to strength, dosage and directions in medication.

Take a look at the basic style guide with the Courtesy of Global Medical Transcription and MT Daily at http://www.mtdaily.com/style.html

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