ACCT NAME LUCILE SALTER PACKARD
CHILDREN'S HOSPITAL
LOCATION
725 Welch Road
Palo Alto, CA 94304
URL
www.lpch.org
------------------------------------------------------------------------------------------QUICKSHOT
Verbatim: Yes
Patient Name: As dictated
Allergies: No special formatting
Headers: All Caps, text on same line.
Account Number Identifier: 2000
Font: Times New Roman 11 –This does not inhibit use of your Word's
zoom function should you like to enlarge your view to better see your
document while working.
-------------------------------------------------------------------------------------------ABBREVIATIONS
Common abbreviations and acronyms are acceptable on this account and are to be
transcribed as dictated unless in the DIAGNOSIS and PLAN sections as per the Acusis
Standards Guide. In this case they are to be spelled out, with the exception of very
common abbreviations such as lab values, CT, MRI, CMV PCR, etc. If you are doing a
procedure note work type if following the PROCEDURE header the actual procedure
name is what is abbreviated then it would be spelled out. For example, ORIF would be
open reduction, internal fixation while MRI-guided biopsy would not be spelled out. Do
not guess at an abbreviation that has more than one meaning. For example, if ALL is
dictated only in the diagnosis and nowhere else in the report clarifies whether it is acute
lymphoblastic leukemia or acute lymphocytic leukemia then it is okay to leave it ALL in
the diagnosis.
If you spell out the uncommon or not easily recognizable abbreviation please add the
abbreviation or acronym following it in parentheses.
The Institute for Safe Medication Practices (ISMP) is devoted entirely to medication error
prevention and safe medication use. They provide the medical industry with safe
guidelines pertaining to medication use and dosing. Please refer to the ISMP Dangerous
Abbreviations list (Do Not Use List of Dangerous Abbreviations on our Intranet) and
apply these guidelines to your transcription for this customer.
-------------------------------------------------------------------------------------------ACCOUNT INSTRUCTIONS - LPCH
1
ALLERGIES
It is up to you if you wish to type these in caps or lowercase; however, do not bold or
underline them.
-------------------------------------------------------------------------------------------BLANKS OR HYPERTEXT IN FILE
A blank is inserted with the Alt+B command. Do not make notes in the report about
what it might be. Use the Has blank(s) Doubt reason. Do not guess at
words/phrases/unfamiliar terminology.
Hypertext is inserted by typing what you think is being said, highlighting the portion in
question, and then invoking the 'blank' command Alt+B. Within brackets now will be
your hypertext guess. You must also flag the report using the Hypertext in report Doubt
reason.
For LPCH, you can send a report to the customer with 3 blanks or less unless it is a letter.
All letters should be reviewed for blanks, unless the blank is a doctor's name or other
proper noun/name that an editor is unlikely to know. This goes for all work types, proper
noun/name blanks or cut-off audio blanks that an editor is unlikely to known should not
be sent to editing. Send these blanks to the customer.
Letters – Any letter with a blank needs to be reviewed by Editing. Due to current process
in routing reports with blanks, a minimum of 3 blank or hypertext bookmarks must be
inserted into the document of the letter. This means, if you have 2 blanks you need to
insert a 3rd or the report will not stop, regardless if you have selected a Doubt reason or
not. So, if you need to insert a 3rd blank bookmark, do so at the top of the report like
this:
-------------------------------------------------------------------------------------------CARBON COPIES
Dictated: CC to Dr. Heather Jones.
Procedure:
1. Search the drop-down cc menu for Heather Jones, M.D. If there is an entry for
Heather Jones, select the entry.
ACCOUNT INSTRUCTIONS - LPCH
2
2. If there is no entry for Heather Jones, M.D. type Heather Jones, M.D. into the freeform cc box.
Dictated: CC to Dr. Heather Jones at 1356 North Street, San Jose, CA 95111.
Procedure:
1. If there is an entry for Heather Jones in the drop-down CC menu, compare the
address and if it matches select that CC from the drop-down menu. If a partial
address is given just matching the city is acceptable for selecting a CC from the dropdown menu.
2. If there is an entry for Heather Jones in the drop-down menu, compare the address
and if it does not match type the name and address into the free-form CC box.
Heather Jones, M.D.
1356 North Street
San Jose, CA 95111
A partial address dictation of a physician not in the drop-down menu can be added to
the free-form CC box as dictated.
Heather Jones, M.D. in San Jose
3. If there is no match in the database for the CC you will need to enter it free-form.
Use the Add button and enter the name and address if dictated. Remember, if you
need to include an address be sure the Address Required box is checked prior to
entering the address.
Also, if you use the free-form CC entry because that recipient is not in our database
you must alert our Customer Support staff by using the Update Physician Info page
on our Intranet. This is located on our Intranet under Transcription Operations. Fill
out the page as completely as possible.
ACCOUNT INSTRUCTIONS - LPCH
3
You do not need to research/Google an incomplete address and add it to the free-form
CC box; the customer prefers to verify addresses on their end. Just type what is
dictated if there is no match in the drop-down menu.
DO NOT select an entry from the drop-down CC menu and also type the name and/or
address into the free-form CC box; use one or the other.
You may add a blank in the name or address if you cannot determine a name/word
like you do in the body of the report.
Note: common to this account are CCs to California Children’s Services (CCS). Many of
these are listed in the drop-down menu and are listed by county (CCS - ‘County’). A
complete list is available on our Intranet. California Regional Center addresses are also
here and are common to this account and are posted on our Intranet.
-------------------------------------------------------------------------------------------CLINICAL AREA CODE
Each report requires a clinical area code. This field is noted in Data Input Window. The
majority of the time this code number is keyed in by the dictator and will auto-populate.
However, there are occasions when the dictator does not key this into the system. In that
case the clinical area code will not populate and you must enter it yourself. Sometimes
the dictators state the clinical area and sometimes they do not. If they do not you need to
refer to the clinical area list (below) and enter it yourself in Data Input Window.
Chronic offenders are dictators from Dermatology, Neurology and Urology.
ACCOUNT INSTRUCTIONS - LPCH
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Code
1
200
202
203
40
42
126
209
210
211
57
213
215
61
62
293
143
268
Clinical Area
Inpatient
Adolescent Medicine
Allergy/Immunology
Audiology
Bone Marrow Transplant
Cardiology
Child Psychology
Craniofacial Anomalies
Craniosynostosis
CV Transplant
Dermatology
Diabetes
Eating Disorders
Endocrinology
ENT
Epidermolysis Bullosa
General Surgery
Genetic Counseling
ACCOUNT INSTRUCTIONS - LPCH
Code
1
3
40
42
57
61
62
65
67
72
77
78
80
81
86
88
96
97
Clinical Area
Inpatient
SDC
Bone Marrow Transplant
Cardiology
Dermatology
Endocrinology
ENT
Ophthalmology
GI
Genetics
Hand
Hematology
Rheumatology
Infectious Disease
Kidney Transplant
Liver Transplant
Nephrology
Neurology
5
72
67
295
77
78
223
81
86
272
88
298
220
96
97
269
100
236
271
270
242
103
65
243
111
310
288
118
119
125
127
80
3
261
148
267
Genetics
GI
Gynecology
Hand
Hematology
Infant Development
Infectious Disease
Kidney Transplant
LIN Research
Liver Transplant
Lung Transplant
Metabolic Genetics
Nephrology
Neurology
Neuro-Oncology
Neurosurgery
OB Genetics
OB PDC
Obstetrics
Occupational Therapy
Oncology
Ophthalmology
Orthopedics
Pain Management
Palliative Care
Pediatric Weight Clinic
Physical Therapy
Plastic Surgery
Primary Care
Pulmonary
Rheumatology
SDC
Speech Therapy
Urology
Vascular Anomalies
100
103
111
118
119
125
126
127
143
148
200
202
203
209
210
211
213
215
220
223
236
242
243
261
267
268
269
270
271
272
288
293
295
298
310
Neurosurgery
Oncology
Pain Management
Physical Therapy
Plastic Surgery
Primary Care
Child Psychology
Pulmonary
General Surgery
Urology
Adolescent Medicine
Allergy/Immunology
Audiology
Craniofacial Anomalies
Craniosynostosis
CV Transplant
Diabetes
Eating Disorders
Metabolic Genetics
Infant Development
OB Genetics
Occupational Therapy
Orthopedics
Speech Therapy
Vascular Anomalies
Genetic Counseling
Neuro-Oncology
Obstetrics
OB PDC
LIN Research
Pediatric Weight Clinic
Epidermolysis Bullosa
Gynecology
Lung Transplant
Palliative Care
-------------------------------------------------------------------------------------------CONFIDENTIAL DOCUMENTATION
ACCOUNT INSTRUCTIONS - LPCH
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A new work type (WT20) now can be used to dictate protected confidential information.
Primarily WT 20 dictations will be used by Psychiatry service or certain specialties when
the complete report is highly sensitive. More commonly the confidential dictation will
occur in other work types (consults, clinic visits, etc.). You do not need to create a WT
20 document. Using the headers below will create the document automatically in postprocessing.
In the course of dictating the dictator will alert you to a confidential portion of dictation.
Each section of confidential dictation should be formatted a specific way. When this
happens, you will insert the normal CONFIDENTIAL SECTION located in the WSWE
Normals.
You insert Normals using the
button (Shift+Alt+Q).
Select the Normal of CONFIDENTIAL SECTION and click on Insert.
It is imperative that you use this header format and only this header format. Do not
deviate from this, do not add other words, etc.
START CONFIDENTIAL:
Type confidential text here, between the headers.
END CONFIDENTIAL:
If they do not indicate when the confidential portion ends and you are unable to
determine this based on context then make it end at the end of the dictation by inserting
the end header at the end of the report.
ACCOUNT INSTRUCTIONS - LPCH
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DO NOT request a CC to the parent when you are using this function.
--------------------------------------------------------------------------------------------
DATA INPUT WINDOW
DATA INPUT WINDOW
Acusis Job Number
Customer Job Number
Customer
auto populate
auto populate
Auto populated--do not change; alert techs if error
Work Type
Clinical Area
Billing Number
DO NOT CHANGE FROM WHAT WAS ENTERED;
but use correct formatting, including the Medication
Header for erroneous work types of 10, 13 and 15.
auto populate; may change if needed
no numbers required
Medical Record Number
Date of Birth
As auto populated, or as dictated; if none given, enter
99999999
auto populate; may change if needed
Last Name
Enter to best of ability as dictated; No Name if none
given
Enter to best of ability as dictated; No Name if none
given
Most residents and NPs/PAs to have attending, but not
all. Use Attending Tab as needed.
First Name
Dictating Physician
Auto populated. Correct in Data Input if needed. If
unknown, leave blank and send to editing with a note.
Dictating Physician ID#
automatically populated
Service Date
►
As dictated or use date of dictation – USE THIS FIELD
FOR DATES
IMPORTANT: Never change the work type in the data entry field if it has been
entered incorrectly by the dictator. Leave the incorrect work type but transcribe
the report as per the appropriate work type dictated. Remember to add the
medications header per requirements if the code is mistakenly keyed as a WT 10, 13,
or 15.
-------------------------------------------------------------------------------------------DATE OF SERVICE SELECTION CRITERIA
BEST MATCH - The customer prefers the exact match, but if there is no exact match
for your service date you can select the next most recent match. Note that some patients
ACCOUNT INSTRUCTIONS - LPCH
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may be seen in a multidisciplinary clinic. Be sure to note the attending physician and
select the best match of ADT.
Please do a manual search if no ADT automatically populates upon opening the job. You
can search by any/all of the criteria available on this page. You can also search partial
names or values by clicking the checkbox next to that field. Click on Search to execute
search function.
To help with searching and selecting ADT, you can look up patient information by both
MRNO and BILLINGNO fields.
Enter the patient’s medical record number in the MRNO field and execute your search, or
enter the FIN (financial) number dictated in the BILLINGNO field.
Dates: (Service Date field) Always use the date of service dictated. If no date is
dictated you may use the date noted in the ADT only if it is the correct match for the
report. If no date is dictated and the date of service is unknown enter the dictation date as
the default service date.
Future Dates/H&Ps: Future dates are allowed for H&Ps. An H&P may be dictated up
to 7 days prior to surgery. If a future date is given as the date of service, use this date as
the date of service.
Dates and Letters: The letter formatting function set dates in letters to be dated the date
of dictation. If the date of service is a different date you must be aware of words like
"today" in your reports. The text needs to make sense, to "match." If the date of the
letter is different from the date of service you will need to either date the letter to the date
of service or change the language in the letter to fit the date of service versus date of
dictation. If the dictator asks the letter to be dated the date of service you will change the
date as instructed.
ADT Information:
2
WORK TYPE
History and Physical
SERVICE DATE FIELD
SHOULD SHOW
Admit Date
ACCOUNT INSTRUCTIONS - LPCH
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Preop H&P
3
4
5
6
Progress Note
Inpatient Consult
Operative Note
Inpatient Letter
7
Discharge Summary
8
Transfer Summary
9
10
11
12
13
14
15
Off-Service Summary
Clinic Visit
EEG/VEEG
Clinic Procedure
Outpatient Letter
Outpatient Consult
Clinic Note/Audiology
As dictated. Could be a future
date if dictated, could be date
the patient was actually seen for
this preop visit.
As dictated
As dictated
As dictated
As dictated
Discharge date or as dictated
NOTE: Service date
autopopulates to default date of
Admit Date – You must change
this to the discharge date.
As dictated or discharge date.
If a timeframe, use the last date
given, the oldest date in the
range, the transfer date, etc.
NOTE: Service date
autopopulates to default date of
Admit Date – You must change
this to the discharge date.
As dictated or discharge date.
If a timeframe, use the last date
given, the oldest date in the
range, the transfer date, etc.
NOTE: Service date
autopopulates to default date of
Admit Date – You must change
this to the discharge date.
As dictated or admit date
As dictated
As dictated or admit date
As dictated or admit date
As dictated or admit date
As dictated or admit date
► This information will be available to you in Data Input Window and View
Header window; however, ONLY the Service Date will carry the date information
through to the customer; however, please change the other date fields accordingly.
It is just good practice to have information show correctly and at some point the
other fields may be viable.
ANY service date (discharge, surgery, consult, etc) must be entered correctly into
the Service Date field using the drop-down calendar.
ACCOUNT INSTRUCTIONS - LPCH
10
If the Service Date field autopopulates to the admit/service date in the ADT when
you make the ADT selection, you may have the change this date accordingly (see
chart above by work type).
If you use the ADT selection to autopopulate data fields using an incorrect ADT
selection you must go back to Data Input Window and correct any dates necessary.
-----------------------------------------------------------------------------------------HEADINGS & SUBHEADINGS
Regarding the title headers at the top of the report, all text following each header indents
to 2.5 (in the Word ruler at the top of your page if you have that toolbar active) and wraps
to the next line.
There are no tabs allowed in the body of the report except those in the title headers at the
top. Do not use hanging indents. All text starts 2 spaces after the header and wraps to
the next line.
Most dictators will say "pediatric" in front of their clinic name. If they do not, you do not
have to have "Pediatric" in front of the clinic name in the report. Using the screenshot
above, you can have Orthopedic Clinic or Pediatric Clinic. If it is not dictated you can
add it. If it is dictated, please use it.
For consistency, headers should be used in reports when any are dictated. For example, if
headers are dictated for indications, history of present illness, medical history, and then
not for social history, please add a header for the social history section. Please use your
judgment with header and be judicious; this is to maintain consistency and not to overtly
change the dictator's style.
The preferred format for the physical examination is with headers that start on a new line,
as below.
PHYSICAL EXAMINATION:
VITAL SIGNS: Text stars 2 spaces after the headers.
HEENT:
NECK:
LUNGS:
CHEST:
HEART:
CARDIAC:
ACCOUNT INSTRUCTIONS - LPCH
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ABDOMEN:
EXTREMITIES:
SKIN:
NEUROLOGIC:
Often the ENT Clinic will expand the HEENT so that there are headers for each system.
There are occasions the physical exams will be dictated in paragraph section or a brief
focused exam. This is okay too. Orthopedics and Dermatology do this frequently. As a
rule, however, the physical examination should fit into the basic physical examination
format with headers. Type it the way it is dictated.
In letters the physical examination can be in either format. Type it the way it is dictated.
(Note: The review of systems in a letter should always be paragraph form. Headers can
be in caps.)
REVIEW OF SYSTEMS – Subheaders can be caps or mixed case; it is your preference,
just be consistent. The exception is Genetics; please use their Normal where the ROS is
formatted similar to the PE.
-------------------------------------------------------------------------------------------
LETTER FORMATS
Letter Button in WordScript (Macro/Short Cut)
If the job you are transcribing is a letter, follow the steps below:
1) Set up the job as usual by saving the Data Input Window and making the ADT
selection.
2) Choose the addressee for the letter from the UpdatePhysicianInfo dialog box (ALTSHIFT-C).
3) Click on the letter icon
.
4) Confirm that date of letter is the date of dictation.
------------------------------------------------------------------------------------------MEDICATIONS FORMAT
All work types 10, 13 and 15 documents now require a header for medications. This
is true for every report regardless of completeness; eg., an addendum or cutoff/incomplete dictation. It is required if the report is incorrectly coded a WT 10,
13, or 15.
Please follow the instructions below:
ACCOUNT INSTRUCTIONS - LPCH
12
1.
If the header Medications: or MEDICATIONS: is dictated, please enter this in the
report where dictated and follow the format instructions in the Transcription
Instructions document on the website. The MEDICATIONS: header should be in
ALL CAPS followed by a colon with the medications listed under the header.
2.
If the header Medications: or MEDICATIONS: is not dictated, please enter this
header after the ALLERGIES: header or section and before the REVIEW OF
SYSTEMS: header or section.
3.
If the medications are not dictated, then a blank (10 underscores) under the header
should be added, i.e.,
MEDICATIONS:
__________
When inserting this blank you can either use 10 underscores or the Alt+B
command.
4.
When medications are dictated they should be transcribed verbatim.
5.
If the dictator states that the medications are “none,” then you should transcribe
none under the header, i.e.,
MEDICATIONS:
None.
6.
If the dictator says that there is no change since (or from) the last dictation, this is
not acceptable. If this occurs you should transcribe, “There is no change from the
last dictation” and then insert a blank (10 underscores), i.e.,
MEDICATIONS:
There is no change from the last dictation. __________.
7.
Do not type CURRENT MEDICATIONS: or anything other than
MEDICATIONS: It must be plural and not MEDICATION:
8.
In the event a report is miscoded in error; i.e., the work type is entered as a 10
when it is really an 05, you must add the MEDICATIONS: header as per
instructions above. Because we never change the work type in the data field we
must add this header or the job will not process to the customer.
-------------------------------------------------------------------------------------------VERBATIM
This account is a verbatim account. Verbatim refers to content. Style issues are per these
customer account instructions and the Acusis Standards Guide. Please transcribe what is
ACCOUNT INSTRUCTIONS - LPCH
13
dictated as closely as possible. Edit grammar, punctuation, spelling and similar dictation
errors as necessary to achieve clear communication. Likewise, edit slang words and
phrases, English or medical inconsistencies, and inaccurate phrasing of laboratory data.
Do not transcribe contractions; always spell out contractions when dictated. Do not
abbreviate medications or use slang medication names; always transcribe the complete
brand-name or generic name of the medication. Do not tamper with the meaning of the
report or with the dictator's style. Editing which leads to rephrasing of the dictation or
tampering with the dictator's style is not allowed.
Regarding use of patient name in report, type what is dictated
-----------------------------------------------------------------------------------------WORKTYPES
02
03
04
05
06
07
08
10
11
12
13
14
15
History & Physical
Progress Note
Inpatient Consultation
Operative Report
Inpatient Letter
Discharge Summary
Transfer Summary
Clinic Visit
EEG/VEEG (video EEG)
Clinic Procedure
Outpatient Letter
Outpatient Consultation
Clinic Note
All Letter work types use the Letter shortcut/hotkey function below.
Clinic visit work types of 10 and 15 are interchangeable at the discretion of the dictator.
All work types except letters (06, 13) require Title Headers (see below). Normals are
also available for template work type formats.
-----------------------------------------------------------------------------------------ATTENDING PHYSICIAN SELECTION
When to add an Attending Physician or Not -When an NP or PNP dictates for an attending they may say something to the effect of:
I, (name of dictator), NP or PNP, am scribing for Dr. Michael Edwards.
Or
ACCOUNT INSTRUCTIONS - LPCH
14
I, (name of dictator) NP or P.N.P., am acting as scribe for Dr. Raphael Guzman.
This may be dictated at any time during the dictation but will usually be dictated at the
end of the report. This may be dictated by any NP dictating for any attending, but is
frequently heard when NPs are dictating for Dr. Michael Edwards and Dr. Raphael
Guzman in Neurology. When dictated it needs to be added to the report. Type as
dictated.
Note: Dr. Darrell Wilson’s name can only be added to his reports or a resident’s report if
they dictate his name. His name is not to be added to any NP reports (no matter what
they dictate).
When a resident MD is dictating the report requires an attending physician. Do not get
this confused with the cases above when an NP is dictating. Hopefully the dictator will
state who their attending is. If not, you can refer to the ADT, but only if the ADT is the
exact match for the encounter. If the ADT is the exact match for the encounter, a resident
MD is dictating and does not state their attending, the ADT will show the attending. The
only exception to this may be if the patient is being seen in a multidisciplinary clinic.
Known your attendings. If you're not sure, flag the report for editing.
Note: For speech, occupation, and physical therapy notes/visits, the therapist is the
attending and no attending MD is required to be added to the report.
-----------------------------------------------------------------------------------------HELPFUL HINTS
- Lucile Salter Packard Children's Hospital is spelled this way, and not with 3 L’s in
Lucile. Common abbreviations physicians/dictators use are LPCH, Packard, Packard
Children's Hospital, and Lucile Packard. All of these are acceptable when transcribing
and should be transcribed as dictated.
-Multi Jobs: Insert a new Template as per WS instructions. Be sure you have selected
the correct Template for your work type/customer. Be sure to re-select any demographic
date for each Template you insert.
- No-Voice and Incomplete Reports: Please be sure to read through all instructions,
as different situations require different instructions.
A. If a job has no audible dictation other than pertinent patient information dictated-meaning there is no actual report text to be transcribed--use the No Voice/Corrupt option
on the Doubt reason window. You do not need to send this report to editing (and will be
unable to if you correctly select No Voice/Corrupt).
ACCOUNT INSTRUCTIONS - LPCH
15
If a dictation ends abruptly, is cut-off or for whatever reason appears to be incomplete, at
the bottom of the report on the left margin type: DICTATION ENDS HERE. You do not
need to send this report to editing for this reason.
1. If a dictator starts dictating and then says "cancel dictation" or any form of "cancel,"
do not send the report. Clear the document and send as a No Voice report.
If you feel you should be compensated for a lengthy report that is cancelled, send a copy
of the report with the line count and job # in an email your operations supervisor about it;
they can address this issue with you. Still send the report as No Voice.
2. If a dictator starts dictating and then hangs up, please handle as such:
a. If the report is less than 10 lines, please clear the report and send as a No Voice.
b. If the report is more than 10 lines, type and send as normal, with DICTATION
ENDS HERE at the bottom of the report.
B. If a dictator states they will add text later, complete the report later, more will be
added, etc. they are wanting the shell of the report to be available to them in the EMR to
complete at a later date. This is NOT a No Voice job. Type the report as usual, entering
all the ADT/demographics, etc., and make a note in the report. See below.
Example dictation: This is Cynthia Wong dictating on patient ……., medical record #
…….. This is an outpatient consultation in the Pediatric Nephrology Clinic on 04/29/09.
Attending physician is ….. End of dictation, text will be entered at a later time, please
add signature lines as indicated.
This can be for any work type. Note: If this is for a work type 10, 13, or 15 report it still
requires the medications header per instructions.
CLINIC:
VISIT DATE:
ATTENDING PHYSICIAN:
Pediatric Nephrology Clinic
04/29/2009
Cynthia Wong, M.D.
MEDICATIONS:
__________
DICTATION TO BE ADDED AT A LATER TIME
-Mary L. Johnson Developmental and Behavioral Unit: This is the developmental
pediatrics clinic at LPCH. At one time it was named the Infant Development Clinic, so
you occasionally hear it called that by some of the seasoned dictators. It is also
frequently called the Development and Behavior Clinic or Unit. Regardless of how it is
dictated, you must use either Mary L. Johnson Developmental and Behavioral Unit if
dictated with the name or Developmental and Behavioral Unit if the name is not dictated.
This is a customer request to maintain uniformity and clarity.
ACCOUNT INSTRUCTIONS - LPCH
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- There are no set content normals (canned text, templates) for this account except for
the EEG canned text. This is posted on the website under Work Types. There are
format normals available for title headers and work types. These are available in
WordScript using the Normals button. These are also posted on our website under Title
Headers by Work Type and Work Types. If using normals with complete formats,
remove headers not dictated/used except for the title headers at the top of the report.
-OPs do not have the date of surgery/procedure on the reports. This is added during
processing; please do not add this to the reports. See format and samples for OP notes on
the website.
-When medications with dosages are given, please transcribe them in a numbered list,
per medications header guidelines. If no dosage are given list format is still preferred,
but paragraph form is acceptable if dictated that way.
-Clinic names should be capitalized when they are used as the entity of the clinic, not the
department.
Patient will be seen in Ophthalmology Clinic.
Patient referred to ophthalmology.
-Diacritic marks:
-No accents, tildes, cedillas, umlauts etc. are allowed on this account. Please check your
Word settings (Word, not WordScript) to ensure these automated marks are turned off.
You may also need to edit your AutoCorrect entries.
In Word, go to Tools, AutoCorrect Options. Go to tab AutoFormat As You Type. No
boxes should be checked in this window. Go to tab AutoFormat. No boxes should be
checked in this window.
-Date formats:
-In non-letter work types please use the abbreviated version for dates MM/DD/YYYY;
i.e. 01/01/2007. Also, when a date is dictated that is Month Day and the year is known
based on the context of the report, please type it in the abbreviated format. This can be
MM/DD/YYYY, M/D/YY, etc. – it is your preference, just be consistent. (I.e., D:
January 12 (Known by context that year is 2008). T: 01/12/2008. Use of a leading zero
in the above format is not required and is per your preference.
In letters please spell out dates; i.e. January 1, 2007. The exception being if dates are
dictated in association with lab values or in a series of 3 or more.
ACCOUNT INSTRUCTIONS - LPCH
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-The entire LPCH Cardiology Department requests that the following terms be
transcribed, at all times, as shown below for every dictator in the cardiology department.
atrial septal
NOT
atrioseptal
ventricular septal
NOT
ventriculoseptal
-Add DATE OF BIRTH: to a report if dictated near the top of the report after VISIT
DATE:
-Do not add titles to reports, e.g., do not type History and Physical at the top of the
document.
Rev 10.07.09
ach
ACCOUNT INSTRUCTIONS - LPCH
18