Introduction to Cardiology Transcription
by Linda C. Campbell, CMT, AHDI-F
The Cardiology Transcription Unit
The SUM Program Cardiology Transcription Unit, 2nd edition, was developed to meet the
growing demand for quality training in medical transcription. Providing four hours of authentic
physician dictation, the unit is designed to simulate on-the-job training within an educational
framework by presenting a variety of cardiology reports with variable dictating styles and
regional and foreign accents.
The reports have been carefully selected in terms of vocabulary density and subject matter,
professionally edited to delete confidential information, and sequenced in a graduated
easy-to-complex fashion for maximum learning and confidence building. They represent
numerous standard and specialized medical and surgical conditions from the vast field of
cardiology.
Sixty-four medical and surgical cardiology reports are offered in this unit. Dictations 1-12
introduce the student to cardiology dictation through history and physicals and admission notes.
Dictations 13-16 are emergency department reports. Dictations 20-28 are state-of-the-art
diagnostic procedures, including electrophysiciologic studies and cardiac catheterization,
arteriography, and ventriculography. Dictations 29-42 are acute-care discharge summaries, while
dictations 43-64 are cardiac operative reports.
Accompanying each dictation is an accurate transcript with explanatory footnotes supplied
where indicated.
Special features of this introduction include informative articles on the art and science of
cardiology from the perspective of both physician and practitioner.
Cardiology Words and Phrases Quick-Reference List (with nearly 900 entries) is included in
the ancillary material to the Cardiology Transcription Unit, 2nd edition.
References
Students should proceed in an orderly and systematic fashion to master cardiology
terminology and various dictating styles. The first step is to obtain the appropriate reference
materials and learn to use them properly.
Dictionaries are essential to accurate medical transcription. A standard English dictionary is
paramount, and an unabridged dictionary offers spellings and plurals not readily found
elsewhere. Basic recommended medical references include the latest editions of Dorland’s
Medical Dictionary; Stedman’s Medical Dictionary; Vera Pyle’s Current Medical Terminology;
Cardiovascular/Thoracic Words and Phrases.
Other useful references include John H. Dirckx’s H & P: A Nonphysician’s Guide to the
Medical History and Physical Examination, 3rd edition; Human Diseases, 2nd edition;
Laboratory Tests and Diagnostic Procedures in Medicine; and HPI’s The Medical Transcription
Workbook, 3rd edition.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
The Reports
Acute-care hospital dictation consists chiefly of the “basic four” reports: History and Physical
Examination, Consultation, Operative Report, and Discharge Summary. Additionally, the
Cardiology Transcription Unit contains several emergency room notes and state-of-the-art
diagnostic procedures.
The History and Physical Examination (H&P). Shortly before or after a patient is admitted
to the hospital, the physician obtains the patient’s history and conducts a physical examination.
These findings are then dictated by category and usually include the patient’s chief complaint
(presenting problem); history of present illness (events leading to the patient’s hospitalization);
past medical history (medical and surgical problems from childhood to present, medications,
allergies); family history (the medical condition of parents and other family members); social
history (the patient’s occupation, lifestyle, habits); review of systems (the medical condition of
the patient’s major organs); and the physical examination.
The physical examination details the physician’s findings on examination of the patient. The
following subheadings are usually dictated: general appearance, vital signs, skin, HEENT (head,
eyes, ears, nose, and throat), chest, breasts, heart, lungs, abdomen, back, extremities, genitalia or
pelvic, rectal, neurologic, and occasionally a mental status exam.
The physician completes the H&P dictation with the admitting diagnosis. A brief description
of proposed treatment (treatment plan) may be dictated as well.
A complete discussion of the history and physical examination can be found in H&P: A
Nonphysician’s Guide to the Medical History and Physical.
The Consultation. A cardiologist or cardiac surgeon may be asked to consult on another
physician’s patient in order to render an opinion regarding the treatment and diagnosis of a
cardiac condition. The Consultation Report usually contains a brief history of the patient’s
illness, the physical findings, pertinent laboratory work, a working diagnosis, and a suggested
course of treatment.
The Operative Report. When a surgical procedure is performed, a detailed, documented
report of the operation is required. The Operative Report usually includes the date of operation;
the duration of anesthesia and operating times (frequently gleaned from written records); the
names of the operating surgeon and assistants; the preoperative and postoperative diagnoses; the
title of the operation performed; the type of anesthesia used; specimens sent to the pathology
laboratory; indications for surgery; the operative findings; and a detailed description of the
operation itself, including suture materials used to close the incision, estimated blood loss,
complications encountered, condition of the patient at the end of the procedure, and if applicable,
the tourniquet time, blood and/or fluid replacement, drains placed, and medications administered.
Some surgeons dictate a postoperative plan.
The Discharge Summary. By the time the patient is ready for discharge from an acute-care
facility, a variety of treatment modalities will have been carried out. The Discharge Summary is
the medical document that summarizes the patient’s course in the hospital, and it is usually
dictated just before or after the patient is discharged from the hospital.
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The Discharge Summary contains the following information: admission and discharge
diagnoses, procedures or operations performed (if any), a brief review of the patient’s history and
the physician’s findings on physical examination, a report of laboratory work performed and
pertinent findings, the patient’s hospital course (including treatment modalities), discharge
medications, and the discharge plan (often referred to as disposition.)
Transcription Technique
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 in this book and to review the table of contents
to gain an understanding of the types of reports you will be encountering. Briefly leaf through the
transcripts so you will know how to set up the various formats.
Building a foundation. The reports in the Cardiology Transcription Unit are sequenced so
that your terminology foundation builds as you advance to the next report. Plan to transcribe each
report more than once, until you become thoroughly familiar with its terminology and competent
in its transcription. While you are learning, you may elect to double-space your transcripts to
facilitate proofreading and error identification. Your draft copy should then be transcribed into a
final error-free copy.
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.
Keep in mind that the transcription of medical reports (medical or technical writing) differs
in technique from the production of essays and manuscripts (formal writing). The latter requires
strict adherence to prescribed format, style, and syntax, and often the writer generates several
draft copies before arriving at a finished polished document.
Medical reports, in contrast, contain many abbreviations, brief forms, shortcuts, and word
coinages that are an integral part of the language of medicine. In the workplace, a first-time final
copy of a medical report is expected, and it is simply not feasible or necessary for the productionoriented medical transcriptionist working in a fast-paced environment to attempt to convert a
medical document into a piece of formal writing or a polished essay.
Occasionally you may encounter a dictation that seems too challenging for you at the
moment. If you find yourself becoming too frustrated or discouraged after an honest attempt at
transcribing a particular report, skip it for the time being and return to it later. However, be
careful not to resort to this practice too often, lest you defeat the purpose of programmed
learning.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
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Pace yourself. First, listen to each report, making 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. 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 (tachyarrhythmia) also present a challenge.
As you gain experience utilizing available resources, you will become familiar with the
techniques of determining sound-alikes 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.
The medical transcriptionist on the job encounters difficult terms as well. When presented
with a questionable word or finding, the practitioner has several options, depending on the work
environment and the employer’s procedures: (1) Seek another transcriptionist’s opinion. (2)
Refer to the patient’s chart or electronic medical record, if available. (3) Send the report to a
supervisor, mentor, or QA specialist. (4) Contact the dictating physician to ask what was
dictated. (5) Leave a blank in the report and flag it to for verification. 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 has a mentoring program for
students), or consult with your classmates.
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.
Do not consult the transcript keys until you have completed a report 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. Follow the
above procedures for each dictation in turn.
Footnotes
The cardiology transcript keys have been prepared with the highest degree of accuracy.
Because this is an advanced dictation 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. When a dictation error occurs repeatedly within a report, it is usually
footnoted only the first time it occurs. The addition of headings for consistency in format and
expansion of abbreviations on first use will be footnoted only once in each report. Reports
requiring little or no editing have no footnotes. Punctuation and grammatical editing changes are
not generally footnoted; specific guidelines for these are addressed below. Footnotes are utilized
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
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to indicate medical dictation errors and to note editorial changes. 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.
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 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.
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.
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.
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 in certain parts of a report (the physical exam for example) may
be defined by clipped sentences, phrases, and single words.
Dictated: No tenderness present over chest.
Transcribed: No tenderness is present over the chest.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
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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 procedure.
Tense. As a rule, the history portion of a History and Physical, Consultation, Discharge
Summary, and Operative Report is generally dictated in past 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 change the report to past 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 are not
dictated, the transcriptionist should supply them as appropriate or flag the report to the attention
of the dictator.
Report Format. There are many acceptable formats for the set-up 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: The extremities are unremarkable.
(Narrative paragraph format.)
Transcribed: Extremities: Unremarkable.
(Narrative paragraph format with subheadings.)
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.)
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
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Lists and Diagnoses. Diagnoses, for which numbers may or may not be dictated, are
generally transcribed in these transcript keys in a numbered vertical format. 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,
such as those that follow the New York Heart Classification (NYHC) for heart disease. In the
transcript keys, we follow the format outlined in “The Value of Using the Entire New York Heart
Association’s Classification of Heart and Vascular Disease,” by J. Willishurst, M.D., MACP of
Emory University, Atlanta, Georgia, USA (Clin. Cardiol. 29, 415–417 [2006]), as follows:
1. Heart Disease
Etiology:
Rheumatic heart disease (mitral stenosis)
Anatomy: Slight right ventricular hypertrophy
Left atrial enlargement
Mitral valve calcification
Physiology: Mitral valve stenosis
Congestive heart failure
Atrial fibrillation (apical rate 160 beats/min)
Pulmonary hypertension
Functional: Class 3
Objective Assessment: C
2. Cancer left breast (operated June 2003)
3. Essential hypertension (controlled with therapy)
4. Anxiety
Physicians often dictate only the functional class, in which case, it would probably simply
follow on the same line with the diagnosis. If you encounter something like this unexpectedly in
the workplace, you should stop and ask for instructions, however, rather than assuming there is
only one way to handle such a situation.
Abbreviations, Brief Forms, Medical Slang, and Symbols
Abbreviations 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 obscured 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, HPI has, in all of its
dictation units, expanded most abbreviations on first use within a report to ensure that the
students were 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
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
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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), electrodiagnostic tests (EMG, EKG,
EEG), imaging procedures (CT, MRI, PET, SPECT, etc.), and metric units of measure 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 (for example, abbreviations like HEENT, CBC, CPR, AIDS, HIV). 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 QA department.
The ISMP Error-Prone Abbreviations List. See the ISMP Website (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 unit
IU
write out International Units
q.d.
(upper and lowercase, with and without periods) translate as daily
q.o.d.
(upper and lowercase, with and without periods) translate as every other day
MS
translate appropriately as morphine sulfate or magnesium sulfate
MSO4
translate appropriately as morphine sulfate or magnesium sulfate
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
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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.
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
exam (examination)
lab (laboratory)
Slang
nitro (nitroglycerin)
lytes (electrolytes)
crit (hematocrit)
alk phos (alkaline phosphatase)
Abbreviation Guidelines for the Cardiology Transcription Unit
When dictated, abbreviations may be transcribed in the body of a report and at the beginning
of a sentence, if their meaning is clearly understood.
ST depression was noted on EKG.
If the dictator abbreviates the title of a major heading within a report, the transcriptionist
should translate the abbreviation.
Dictated: CV:
Transcribed: CARDIOVASCULAR:
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. In instances
where translation of the abbreviation may confuse rather than clarify, the abbreviation should be
retained.
Dictated: An AAA was discovered on echocardiography.
Transcribed: An abdominal aortic aneurysm (AAA) was discovered on
echocardiography.
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Dictated: The AICD was set in the DDD mode.
Transcribed: The automatic implantable cardioverter defibrillator (AICD) was set in the
DDD mode.
EKG leads. Subscripts are not used for the V1 through V6 leads because special characters
do not transmit well electronically. The standard limb leads are identified by Roman numerals.
V1 through V6
leads I, II, and III
aVF, aVL, aVR
Heart sounds. Similarly, subscripts are not used for the heart sounds S1 through S4 and A2
and P2.
ST segments and T waves. The frequently dictated expression ST-T wave changes has
become so ubiquitous that its use is widely accepted. A fuller statement would be “ST-segment
and T-wave changes,” to avoid the implication that what is meant is “ST-wave and T-wave
changes.” Most dictators probably say “or” in the negative statement, “No ST or T-wave changes
are noted,” or its many variations. Again, inserting segment after ST would make the statement
clearer, but it is not required. If “ST-segment and T-wave changes” is transcribed, the hyphens
should be used because ST-segment and T-wave consistute compound adjectives. The phrase
“ST-T segment deviation,” which is found in some word books, is simply wrong. There is an ST
segment (the part of the ECG tracing extending from the S wave to the T wave) and there is a T
wave, but one cannot speak of an ST-T segment, much less an ST-T segment deviation.
Symbols. The symbol x may be used to represent the word times (bleeding x3 days). It is also
used to represent by in measurements (3 x 5 cm).
The percent symbol (%) should be used with numerals; in a range, the symbol should be
repeated with each value (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
98.6ºF
37 degrees Celsius
98.6 degrees Fahrenheit
Numbers
Avoid beginning a sentence with a numeral. Either write out the number or alter the
beginning of the sentence.
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Dictated: 2 mL of Xylocaine was given.
Transcribed: Two milliliters of Xylocaine was given.
Xylocaine 2 mL was given.
Then 2 mL of Xylocaine was given.
Dictated: 45-year-old black male
Transcribed: A 45-year-old black male or
This is a 45-year-old black male or
This 45-year-old black male (if verb follows)
Dictated: 5-FU therapy was given.
Transcribed: Therapy with 5-FU was given.
The transcriptionist should enumerate a long list of diagnoses, whether or not numbers are
dictated. When the dictator numbers the diagnoses, retain the numbers unless there is only one
diagnosis.
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 sizes may or may not be dictated with a number sign. As a general rule, transcribe as
dictated. However, when the suture size is a whole number, the number sign may be added for
clarity.
00 or 2-0 or #2-0 Dexon suture
#1 Tevdek suture
Units of Measure
It is customary to abbreviate metric measurements in medical reports. 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)
mmHg (millimeters of mercury)
inch
foot
Metric measurements in this transcription unit follow the recommendations of the SI system
(Système International d’Unités); for example, cm (centimeters), mL (milliliters), and g (gram).
Fractions should be converted to decimals when they are used with metric units of measure,
and decimals should be converted to fractions when they are used with standard units of measure.
0.25 cm
1/4 inch
3.5 mL
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Note: 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.
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 zero and the decimal 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
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 4
Transcribed: 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 pleural cavity.
Word Forms
Alternative spellings. Some words have more than one acceptable spelling, and the
preferred spelling may vary from reference to reference.
anulus (not annulus)
PR interval, P-R interval
transected, transsected
long-standing, longstanding
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 femoropopliteal
inferior-lateral or inferolateral
tracheal-bronchial or tracheobronchial
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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
Punctuation
Standard 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.
QT interval or Q-T interval
1 mm ST segment depression
3 cm incision
The prefix post is not generally 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 myocardial infarction.
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.
swanlike
uppermost
seizure-like
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, midlateral).
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com
A hyphen is not needed to connect a single letter and noun combination, such as J point and
T wave; however, a hyphen is used to join a single letter and noun when they function as a
compound adjective (ST-segment depression and T-wave changes).
Compound designations of Americans identified by ethnicity, race, or nationality are no
longer hyphenated, either as nouns or adjectives.
Japanese American male
Mexican American female
Colon/Capitalization. Capitalize the first word following a colon in a heading or
subheading.
HEART: The heart sounds are strong on auscultation.
Possessive Eponyms
The use of the apostrophe plus s (’s) to form a possessive eponym is optional. The reports in
this unit were transcribed verbatim, and the ’s was used only when the physician dictated the
possessive form.
Starling mechanism or Starling’s mechanism
Wenckebach phenomenon or Wenckebach’s phenomenon
Eponymic adjectives in Cardiology Words and Phrases: A Quick-Reference Guide are
presented without the possessive form, for simplicity.
Summing It Up
This 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.
Cardiology, The SUM Program Advanced Medical Transcription Unit, 2nd ed.
Health Professions Institute
www.hpisum.com