General Medical Transcription Rules

A medical transcriptionist interprets and transcribes dictations by healthcare professionals into text format. These transcribed documents are essential to timely and accurate healthcare records. Proper training and guidance in the medical transcription industry will lead to proficiency in the areas of medical terms, editing, typing and listening simultaneously and use of medical transcription software.
It is important to be well informed about the industry, the profession, and the educational process for your career. Meditec consults with industry experts to ensure a great learning experience to excel in the medical transcription industry. The course generally includes coursework in medical root words, suffixes, and prefixes, pharmaceutical terminology, how to transcribe in real-world situations and surgical vocabulary.

Getting started for a medical transcription career

We have prepared a medical transcription guide to aid you in taking your course. Here is a partial list of the general medical transcription rules you need to observe in transcribing and editing documents:

1. Spacing With Punctuation Marks

Do Not Type a Space …
before or after a hyphen
before or after a slash
before or after a dash
between a number and percent sign
between parentheses and the enclosed material
between any word and the punctuation following it.
between the number and the colon used to indicate a dilute solution or ratio, e.g. 1:4
on either side of the colon when expressing the time of day
before an apostrophe
before or after a comma used within numbers
before or after an ampersand in abbreviations, e.g., C&S
on either side of the colon when expressing ratios e.g. 1:1
after the closing parenthesis if another mark of punctuation follows
when using the word “times” as x – e.g., x3

Type One Space…
between words
after a comma
after a semicolon
after a period following an initial
after the closing parenthesis
on each side of the x in an expression of dimension, e.g. 4 x 4 type 2 spaces…
after punctuation at the end of a sentence
after a colon except when expressing time or a dilution ratio

2. Numbers

Spell out WHOLE numbers zero through nine, use numerals for 10 and above (this may change in the near future as the AAMT is trying to standardize using numerals only.

Use numerals when numbers are directly used with symbols.
Use numerals when expressing ages.
If it is an approximate age, spell it out.
Use numerals to express size and measurements.
Use numerals for everything metric. Centimeters, millimeters, liters, etc.
Use numerals in all expressions pertaining to drugs – this includes strength, dosage and directions. Z-PAK 2 daily on day 1, then 1 daily on days 2-5.
Spell out and hyphenate fractions standing alone. He drank one-half a gallon of apple juice.
Use numerals to express mixed fractions. 1 1/2 years.
Use commas only if there are 5 or more digits when expressing numbers. e.g. 10,000, 4000.
Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration.
Substitute a hyphen for the word “to”. He is to take 1-2 tablets of Tylenol every 4-6 hours p.r.n.
Leave a space between numerals and measurements unless they form a compound modifier. It is 6 cm below the …… It is 1200 mL……. A 4-cm nevus……. A 2 x 2-mm lesion…….
Always use 0 in front of the decimal point if the number is not a whole number. 0.75 mg
Use decimal fractions with metric measurements. 1.5 cm
Use mixed fractions with English system measurements. 1 1/2 inch
Use numerals for: Ages, units of measure, vital statistics, lab values and in other instances where it is important to communicate clearly the number referenced. Examples: 4 inches, 3-year-old. She has three dogs who have eight fleas each. A total of 7 basal cell carcinomas removed from his left arm. (7 for clarity)
Do not start a sentence using a number. Spell out the number or recast the sentence.
Dictated as: 10 milligrams of Reglan was administered stat. Transcribe as: Reglan 10 mg was administered stat.
Exception – It is acceptable to begin a sentence with a date. Example – 2004 is going to be a prosperous year.
Plurals – do not use an apostrophe to form plural numbers.
4 x 4s
She was in her 20s or twenties (this is acceptable because it is not a definite number).
She was born in the 1970s.
Series of numbers – Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction.
Example – Jeff has 1 job, 1 place of employment and 18 hours a day to do the work.
Cranial nerves – Preferred: Roman numerals I-XII
Diabetes type 1 and type 2, not Roman numerals I and II – this was recently standardized by the American Diabetes Association.
Apgar scores – Use numerals for ratings and spell out numbers relating to minutes. Rationale – to draw attention to the scores. Example: The Apgar scores were 6 and 9 at one and five minutes. Apgar is not an acronym.

Time Examples
8:30 a.m. – morning
8:30 p.m. – evening
noon, not 12:00 noon
midnight, not 12:00 midnight or 12 ‘o’clock or 12:00 p.m.

3. Measurements

Spell out all nonmetric measurements. Feet, inches, pounds, ounces, yards, grain, dram, etc.

Use tsp for teaspoon
Use tbsp for tablespoon
Abbreviate all metric measurements.
Use F for Fahrenheit IF accompanied by the symbol for degree. 98.6°F
Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit.
Use C for Celsius IF accompanied by the symbol for degree. 36°C
Spell out Celsius IF degree is spelled out. 36 degrees Celsius.

In tables and technical documents:
Use ft or ‘ for feet
Use ” for inches
Use yd for yard
Use pt for pint
Use oz for ounce
Use fl oz for fluid ounce

Abbreviate most unusual units of measure when accompanied by numerals Dictated as Transcribed as:

0.8 centimeters squared 0.8 sq cm
22 milligram of mercury 22 mmHg
3.0 liters per minute 3.0 L/min
40 millimeters per hour 40 mm/h
8 grams percent 8 gm%

4. Symbols
Spell out a symbol when used alone (with no number).
Use symbols when they are used with numbers
Common Symbols

Dictated as Transcribed as:

Four to five 4-5
Number 3 0 #3-0
Twenty-twenty vision 20/20
BP 120 over 80 120/80
Grade two over six 2/6
A positive A+
Three point five centimeters 3.5 cm
Point five centimeters 0.5 cm

5. Capitalization

Abbreviations when the words they represent are capitalized
The first word following a colon if it begins a complete sentence or is part of an outline entry
Most abbreviations of English words
The first letter of chemical elements
The names of the days of the week, months, holidays, historic events and religious festivals
The names of specific departments or sections in the institution only when the institution name is included
The names of diseases that include proper nouns, eponyms or genus names
The trade or brand names of drugs
A quote when it is a complete sentence
The names of races, peoples, religions and languages. Black, as a race designation would be capitalized, however client preferences may differ.

Do Not Capitalize…
The spelled out names of the chemical elements
The seasons of the year
The common names of diseases
The names of viruses unless they include a proper noun
Generic drug names
The common noun following the brand name. Example – Tylenol tablets
The names of medical or surgical specialties
Designations based on skin color, like “a tall white man.”

6. Hyphenation

These prefixes do not require the use of a connecting hyphen in compound terms:
ante intra semi
anti micro sub
bi mid super
co non supra
contra over trans