Acusis Standards Guide
If they differ, the account specific instructions supersede these Standards.
OBJECTIVE
The purpose of this document is to provide clear and concise transcription standards for employees of
Acusis.
DISCLAIMER
This document is meant to serve as a general preferred style guide only. The goal is consistency among
employees across all accounts and platforms. It is not intended to be an all-inclusive grammar reference,
nor is it meant to replace customer-requested formats or style.
HOW TO USE THIS DOCUMENT: This document contains an alphabetized list by topic for
transcription standards that have been adopted by Acusis. It also contains appendices of acceptable
terms, unacceptable terms, and sound-alike words. When searching for a specific topic, click on the
appropriate hyperlink in the Table of Contents, which will take you directly to that section in the
document.
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Page 1
TABLE OF CONTENTS
To navigate through this document, click on any of the hyperlinks in the Table of Contents. This will
take you to that section in the document. Since Acusis employees use their own computer, not everyone
has the same version of Word, which could impact the functionality of the hyperlinks.
If the hyperlink does not function for you, try the following:
 Hold down the Control key and click on the selected hyperlink.
If that does not work, try un-checking the field codes and bookmark boxes:
 Open Word, click on Tools, click on Options, and then click on View. Uncheck the Field Codes
box and the Bookmark box.
To return to the Table of Contents quickly, click on the hyperlink called Return to Table of Contents,
located at the bottom of each section in this document.
1. Abbreviations
2. Acronyms
3. Ages
4. APGAR vs. Apgar score
5. Brief Forms/Slang
6. Cancer Classifications
7. Capitalization
8. Cardiology Terminology
9. Coined Terms
10. Colons
11. Commas
12. Conjunctions
13. Contractions
14. Dates
15. Diabetes Classifications
16. Diagnosis Report Headings – “Same”
17. Disk vs. Disc
18. Eponyms
19. Familial Relationships
20. Followup vs. Follow-up vs. Follow up
21. Genetics
22. Genus and Species
23. Hyphens
24. Laboratory Data
25. Latin
26. Measurements
27. Medications
28. Neologisms (CoinedTerms)
29. Numbers
30. Obstetrics
31. Offensive Language/Obscenities
32. Patient’s Name in Text
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33. Percent Symbol
34. Plurals
35. Possession
36. Prefixes
37. Pro time
38. Proper Nouns and Eponyms
39. Ranges
40. Ratios
41. Risk Management Issues
42. Scales and Scores
43. Semicolons
44. Stat
45. SutureSizes
46. Symbols
47. Temperature
48. Time/Clock References
49. Times (as in “Times Two”)
50. Verbs
51. Vertebrae
52. Virgule
53. Years
Appendices
Appendix A: Unacceptable Terms
Appendix B: Acceptable Terms
Appendix C: Words that sound alike or look alike
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ABBREVIATIONS
Unless account specific instructions state otherwise, abbreviations and acronyms are to be transcribed as
dictated, except in the following instances:




Under diagnostic headings, only disease-related abbreviations or acronyms need to be expanded.
Non-disease acronyms or abbreviations for procedures, tests, measurements, etc., do not need to
be expanded (e.g., CT, MRI, cm, BUN)
Spell out all standard (nonmetric) units of measure: feet, inches, yards, pounds, ounces, grains,
joules, etc.
Abbreviations or acronyms are to be expanded only when the meaning is clear. When in doubt
(when an abbreviation or acronym can have multiple meanings or you are not sure which is
intended), transcribe the abbreviation or acronym as dictated, e.g., ASHD, BPH, CLL, TTE.
Psychiatric Diagnoses: The abbreviations NOS (not otherwise specified) and NEC (not
elsewhere classified) are part of the diagnostic statement and should be expanded, unless account
specific instructions state otherwise.
When expanding an abbreviation or acronym that is preceded by a diagnostic heading, it should be
followed by the dictated abbreviation in parenthesis. If no abbreviation is dictated, do not add it.
Example:
Dictated: Admitting diagnosis, history of COPD.
Transcribe: Admitting Diagnosis: History of chronic obstructive pulmonary disease (COPD).
Expand when preceded by the following diagnostic headings:
Assessment/Impression
Conclusion (of consultation)
Diagnosis(es)
Operation or Procedure
Trade Name Drugs: See Medications section for information on abbreviations in trade names.
Blood counts:
 RBC, rbc: Either form is acceptable as an abbreviation for red blood count or red blood cells.
 WBC, wbc: Either form is acceptable as an abbreviation for white blood count or white blood
cells.
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ACRONYMS
An acronym, usually formed from the initial letters of a title or phrase, is an abbreviation that forms a
pronounceable word. Acronyms are to be written in all capitals, without punctuation.
Examples:
AIDS, CABG, PERRLA, SOAP, TURP, SMAC
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AGES
Arabic numerals are preferred for transcribing ages, except at the beginning of a sentence.
Examples:
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The patient is a 12-year-old male.
Twelve-year-old Michael…
The patient is a 7-year 7-month-old (or 7-year-7-month-old) female.
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APGAR vs. Apgar score
APGAR is an acronym for a family assessment instrument: Adaptability, partnership, growth, affection,
resolve.
Apgar score (Apgar is initial case only) is an assessment of a newborn’s condition; it was named after
the physician who developed it. Write out the numbers related to minutes, in order to avoid confusion
and to draw attention to the scores. Examples:
 Apgars 7 and 9 at one and five minutes.
 Apgar scores were 5 at one minute, 7 at five minutes, and 9 at ten minutes.
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BRIEF FORMS/SLANG
Avoid transcribing dictated slang unless account specific instructions specify strictly verbatim
transcription. For a list of commonly misused, unacceptable terms, see Appendix A. If a term may be
documented as a stand-alone word, e.g., phone, exam, lab, etc., it is not considered a brief form.
Commonly used short forms of laboratory terms may be transcribed as dictated, e.g., eos, basos, segs,
polys, etc., except in headings, diagnoses, or operative titles, unless account specific instructions state
otherwise. For a list of commonly used acceptable terms, see Appendix B.
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CANCER CLASSIFICATIONS
Stage and grade
 Stage and grade: Do not capitalize except at the beginning of a sentence.
 Roman numerals are used to express cancer stages.
 For subdivision of stages, use capital letters, Arabic numerals, no hyphen or spaces.
 Arabic numerals are used to express cancer grades.
stage or grade:
stage 0
stage I
stage II
stage III
stage IV
stage IA
stage II3
grade 1
grade 2
grade 3
grade 4
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Tumor, node, and metastasis (TNM) is the staging system for malignant tumors.
 T = tumor size or involvement
 N = regional lymph node involvement
 M = extent of metastasis
When numbers are used in conjunction with TNM (indicating degree of positive findings), use
Arabic numerals, no spaces. Example: T1N1M0
Clark level is expressed in Roman numerals. Example: Clark level III
Gleason score is expressed in Arabic numerals. Example: Gleason score 8
COG (Children's Oncology Group) protocols are written as a single unit, i.e., no hyphen should be used,
e.g. AALL02P2, ANBL00B1, etc., whereas POG (Pediatric Oncology Group) protocols are written as a
double unit, i.e., POG 9645, etc.
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CAPITALIZATION
 Department Names: The general rule is that department names are not capitalized.
Hint: If the department name is preceded by an article, it is not capitalized.
Examples:
The cardiology service was consulted.
An orthopedics consult was requested.
The pathology department reported the margins as negative.
Exception: Capitalize department names when mentioned as entities.
Hint: Substitute a noun, such as "Dr. Smith." If you can replace the name of the department
being dictated with "Dr. Smith" and the sentence still makes sense grammatically, it is being
used as an entity and is capitalized.
Examples:
The patient was monitored by Anesthesia.
The specimen was sent to Pathology.
A referral to Dermatology was issued at the patient's request.
 Rooms or Locations: Divisions or specific locations within departments are not capitalized
(e.g., the emergency room, the operating room, recovery room).
Examples:
The emergency room was fast and efficient.
Patient taken to recovery room after procedure.
He was taken to the surgical suite this afternoon.
The patient was moved to the intensive care unit.
 Business Names: Capitalize all the words in business names except for articles and prepositions
(Hospital Corporation of America), or use the corporate spelling (TelSim, eBay). Capitalize the
words Association, Company, Institution, or Organization only if those words are part of the
business name (American Hospital Association, Starbucks Corporation).
 Proper Names: Do capitalize names of hospitals, clinics, office buildings, and businesses
representing proper nouns and official names.
Examples:
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The patient attended Greenville Physical Therapy for her rehabilitation.
She was treated at General Hospital a few weeks ago for similar complaints.
He has an appointment next week at the Oak Street Family Medicine Clinic.
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CARDIOLOGY TERMINOLOGY
Electrocardiograms:
 Either ECG or EKG is an acceptable abbreviation for electrocardiogram. Transcribe as dictated.
 Bipolar leads are transcribed using Roman numerals, and lead is lowercase: leads I, II, III.
 Limb leads are lowercase ‘a’ followed by capital ‘V’ and the limb: aVR, aVL, aVF. (R = right;
L = left; F = foot).
 Precordial leads are expressed with a capital ‘V’ followed by an Arabic numeral: V1, V2, V3,
V4, V5, V6, V7, V8, V9.
 Hyphenate tracing terms when they contain compound modifiers preceding a noun. Examples:
ST-segment depression, T-wave abnormality, non-Q-wave myocardial infarction.
 An ST segment and T wave are 2 separate terms; however, physicians often dictate them
together (i.e., ST and T wave or STT wave) which implies they mean ST wave and T wave. To
ensure this is not confused, type as follows:
Dictated: STT wave abnormality
Transcribe: ST and T-wave abnormality or ST-T-wave abnormality
Heart murmurs
 Arabic numerals are used to designate heart murmurs.
 When describing heart murmur grades, a virgule (slash) is used to separate the grade from the
scale.
Example:
Dictated: …a grade two over six soft holosystolic murmur.
Transcribe: …a grade 2/6 soft holosystolic murmur.
 Progressive murmurs: Do not use a hyphen to replace the word to when transcribing a range
(progressive heart murmur).
Example:
Dictated: …a two to three over six murmur.
Transcribe: …a 2/6 to 3/6 murmur or a 2 to 3 over 6 murmur.
Thrombolysis in myocardial infarction (TIMI)
 TIMI is expressed in grades (0-3) of flow. Lowercase grade and Arabic numerals. Example:
TIMI grade 2 flow
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COINED TERMS
See section below called Neologisms.
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COLONS
A colon is used to call attention to the information that follows. Some uses of the colon include the
following:
 Introduces a list or series.
Example: The patient had the following complaints: not sleeping enough, eating too much, and
not getting enough exercise.
 Separates two independent clauses when the second clarifies the first.
Example: In the ER we have an important saying: If you did not write it in the chart, it never
happened.
 Separates numerals in ratios, e.g., a 2:1 mixture, epinephrine 1:100,000.
- Do not substitute a hyphen for the colon when used to separate values (numbers) in a ratio.
- However, spell out the word to and hyphenate when expressing the ratio using words or
letters.
Example: I-to-E ratio, myeloid-to-erythroid ratio.
 Follows the salutation in a business letter, e.g., Dear Mr. Hughes:
Colons and semicolons are not interchangeable.
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COMMAS
A comma is used in the following instances:






To separate items in a series.
Examples:
He opened the letter, read it, and made a note of its contents.
He is to take Lasix 40 mg b.i.d., Colace 100 mg daily, and Lipitor 1 daily.
Note: Do not omit the final comma that separates the last 2 elements.
To separate multiple adjectives preceding a noun. Exception: If the descriptors preceding the
noun are age, race and/or gender, they may be treated as a single unit and no comma is
necessary.
Example:
This young, bright, slender woman was a candidate.
but
This 29-year-old white male was admitted through the emergency room.
When the month, day, and year are dictated in that order, and text follows the year, set off the
year by commas.
Example: The patient was admitted on Tuesday, April 15, 2005, by Dr. Smith.
To clarify a preceding phrase.
Example: Dr. Fred Flintstone, Chief of Medicine.
To set off a parenthetical expression.
Example: The patient had a ruptured appendix, not an ovarian cyst, which we removed in the
operating room.
To separate a compound sentence when the independent clauses are joined by a conjunction.
Example: The patient’s condition was critical, but we felt we could save him.
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CONJUNCTIONS
A conjunction is a word or phrase that connects words, other phrases, or clauses.
Coordinating conjunctions: Connect words, phrases or clauses of equal rank. Coordinating
conjunctions are: and, but, or, and nor. They are usually preceded by a comma, and sometimes by a
semicolon or colon.
Example:
The patient was very ill, but she was not admitted.
Correlative conjunctions: Conjunctions consisting of 2 elements which must be used in pairs: both …
and, not only … but (also), either …or, neither…nor. When using either…or and neither…nor, match
the number of the verb to the number of the nearest subject.
Examples:
Neither the brother nor the sisters have the illness.
Neither the sisters nor the brother has the illness.
If subjects before and after or and nor are both singular, use a singular verb; if both are plural, use a
plural verb.
Examples:
Neither the brother nor the sister has the illness.
Neither the brothers nor the sisters have the illness.
Subordinating conjunctions: Conjunctions used to join unequal parts (dependent clauses to main or
independent clauses): while, when, where, after, before, if, since, yet, so. In most cases, a comma
precedes these conjunctions.
Example:
The patient was very pale, yet he refused treatment.
Conjunctive adverbs: Used to connect two independent clauses: consequently, finally, furthermore,
however, moreover, nevertheless, similarly, subsequently, then, therefore, thus. Conjunctive adverbs are
usually preceded by a semicolon (sometimes a period) and usually followed by a comma.
Example:
The day was dark and dreary; however, the day was very warm.
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CONTRACTIONS
Contractions are not used in medical reports except in direct quotes or if account specific guidelines
instruct otherwise.
Example:
Dictated: The patient hasn’t kept her appointments.
Transcribe: The patient has not kept her appointments.
Dictated/Transcribe: The patient stated, "I'm more tired than ever. I don't seem to be adjusting well to
this new medication dosage."
Tip: Do not confuse the possessive form of the personal pronoun (its) with the contraction it's (it is)
Example: The cat was licking its paws in the window where it’s sunny.
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DATES
 When the only text following a major heading is a date, transcribe using virgules, with 4-digit
year, (not followed by a period). Example:
DATE OF OPERATION: 12/15/2007
 In the body of the text, spell out the dates unless otherwise specified in the account instructions.
Example:
The patient was seen in the clinic on December 15, 2007.
 Ordinals cannot be used in month, day, year format.
Example:
Dictated: The patient was seen on September 30th 2005.
Transcribe: The patient was seen on September 30, 2005.
 Ordinals can be used when the day of the month is dictated prior to the month, and the date is
preceded by the word “the.” A comma is not used following the month: the 5th of May 2006.
 Ordinals may be used when the year is not dictated: I saw the patient on September 17th and
October 22nd. However, it is preferable to drop the ordinal and add the year if the year is known.
Example:
Dictated: I saw the patient on October 22nd.
Transcribe: I saw the patient on October 22, 2007. (only if the year is known)
 Do not use a comma if the day of the month is not dictated: December 1987.
 Use a comma to separate the year from the rest of the date when the day of the month is dictated:
December 21, 1987.
 Use a comma after the year when the sentence continues after a date is dictated.
Example: I saw the patient on September 17, 2003, at which time he had a physical.
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DIABETES CLASSIFICATIONS
Use Arabic numerals to identify types of diabetes: type 1 and type 2.
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DIAGNOSIS REPORT HEADINGS – “SAME”
Do not transcribe “same” when an author dictates it as the discharge diagnosis or the postoperative
diagnosis. Transcribe the diagnosis in full.
Examples:
Dictated: Admission diagnosis bilateral inguinal hernia. Discharge diagnosis the same.
Transcribe: ADMISSION DIAGNOSIS: Bilateral inguinal hernia.
DISCHARGE DIAGNOSIS: Bilateral inguinal hernia.
Dictated: Preoperative diagnosis acute appendicitis. Postoperative diagnosis the same.
Transcribe: PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
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DISK VS. DISC
Disk: The term disk should be used for all anatomic terms, except as regards ophthalmology: L5-S1
disk; diskectomy.
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Disc: Use the term disc for all references to the optic disc in ophthalmology.
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EPONYMS
See section called Proper Nouns and Eponyms.
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FAMILIAL RELATIONSHIPS
Transcribe familial relationship terms such as "mom" and "dad" as dictated. Do not change to the
formal mother and father. Capitalize family titles (mother, father, mom, dad, etc.) when they stand
alone or are followed by a personal name.
Examples:
I counseled Mom to use a 50:50 mixture of alcohol and vinegar to clean the ears.
He came to the office today with Uncle Harry.
At discharge, Dad was instructed to keep the patient’s wound clean and dry.
Do not capitalize family titles when a possessive or an article precedes them.
Examples:
I spoke to his mom and dad about the need to strictly adhere to this medication regimen.
The patient’s sister accompanied her on this office visit.
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FOLLOWUP vs FOLLOW-UP vs FOLLOW UP
Use followup for the noun and adjective forms. The hyphenated form, follow-up, is an acceptable
alternative when used as an adjective. These guidelines also apply for work up, work-up and workup.
 The patient did not return for followup. (noun)
 In followup visits (or follow-up), she appeared to improve. (adjective)
For the verb, the two-word form follow up is the only correct choice.
 We will follow up with regular return visits. (verb)
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GENETICS
Place a comma (without spacing) between the chromosome number and the sex chromosome. Use a
virgule to indicate more than one karyotype in an individual: The normal human karyotypes are 46,XX
(female) and 46,XY (male).
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GENUS AND SPECIES
 Genus names are capitalized when followed by a species name. Example:
Staphylococcus aureus
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

It is acceptable to abbreviate the genus if dictated; however, do not abbreviate the species, even
if dictated. No period is needed when abbreviating the genus. Examples:
H influenza (not H flu)
S aureus
Genus names are not capitalized in plural or adjectival forms, or when they stand alone.
Example:
The specimen showed staphylococci.
The patient had a staphylococcal infection.
He was diagnosed with staphylococcus.
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HYPHENS
 When two or more words are combined to form a compound adjective preceding a noun, a
hyphen is usually required.
Example: The patient is a well-developed, well-nourished male.
 No hyphen is used if the adjective follows a verb.
Example: The patient was well developed and well nourished.
 Use hyphens in the following instances:
o For clarification (re-cover, re-create)
o With compound words formed with the prefix self- (self-care)
o With proper nouns and numbers (non-Hodgkin lymphoma, pre-2002 history)
o To join an adjective to a participle, whether the compound precedes or follows the noun
(good-natured, soft-spoken)
 It is no longer preferred style to use a hyphen between a number and a metric unit of measure
preceding a noun.
Example:
Dictated: Patient had a four centimeter wound.
Transcribe: Patient had a 4 cm wound. (Previously, the preferred style was 4-cm.)
 It is no longer preferred to hyphenate designations of persons by race or ethnicity: African
American, Asian American, French Canadian, Mexican American, Native American, etc.
 Use hyphens in most compound adjectives that contain a preposition (to is the preposition in the
following examples): Examples:
o finger-to-nose test
o wet-to-dry dressing
 Use a suspensive hyphen after each incomplete modifier when there is a series of hyphenated
compound modifiers with a common last word that is expressed only after the final modifier in
the series.
o 10- to 12-year history
o full- and split-thickness grafts
 If one or more of the incomplete modifiers is not hyphenated, repeat the base with each,
hyphenating or not, as appropriate.
o preoperative and postoperative diagnoses
not pre- and postoperative diagnoses
 Other examples of correct use of hyphens are as follows: month-to-date, figure-of-eight suture,
excision of L5-S1 disk (hyphen used to signify the intervertebral disk space), ST-T wave
abnormality (see Cardiology Terminology section for full explanation).
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LABORATORY DATA
 Do not use a comma to separate a lab value from the name of the lab test.
Example: Hemoglobin 14.6
 Separate related lab data by commas, and unrelated data by semicolons or periods.
Example: Hemoglobin 14.6, hematocrit 38, platelets 286,000. BUN 12, creatinine 1.3; glucose
112.
 Do not expand metric units of measure if accompanied by a numeral.
Example:
Dictated: Creatinine measured 0.7 milligrams percent
Transcribe: Creatinine measured 0.7 mg%.
 Transcribe lab values as dictated.
Example:
Dictated: platelets two sixteen
Transcribe: platelets 216, not 216,000
Note: If “two hundred sixteen thousand” is dictated, transcribe as 216,000.
 Urine specific gravity is always transcribed as a single numeral followed by a period and 3
additional numerals.
Example:
Dictated: specific gravity ten ten
Transcribe: specific gravity 1.010
 Use numerals to express lab values. Insert a leading zero and a decimal in dictated metric
measurements of less than one (0.6).
 Do not drop a dictated zero, which may be used to indicate a very specific value: If three point
zero is dictated, it is transcribed as 3.0. Alternately, if a whole number only is dictated as a lab
value (e.g., creatinine of 1), do not add a decimal point and zero.
 Thousand/million measurements:
Examples:
Dictated: White blood count four point eight thousand.
Transcribe: White blood count 4.8 thousand or white blood count 4800.
Dictated: Platelets one point five million.
Transcribe: Platelets 1.5 million or 1,500,000.
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LATIN
It is acceptable to combine Latin and English expressions, if dictated.
Examples: q. day, q. week.
Use a comma both before and after a Latin expression, except when listing drugs and dosing
instructions.
Example: I will see the patient when she returns from her vacation, i.e., in 2 weeks.
Use lowercase with periods for Latin abbreviations: b.i.d., t.i.d., q.i.d., etc.
Insert a space after the numeral in q.4 h. (could be any number of hours – this example reflects 4 hours)
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MEASUREMENTS
 Spell out all standard (nonmetric) units of measure: feet, inches, yards, pounds, ounces, grains,
joules, etc.
 Height: Always express height in feet and inches. Do not use the symbols: ’ or ”. The
expression “foot” is incorrect with any height or length over 1 foot.
Example:
Dictated: The patient is five foot two inches.
Transcribed: The patient is 5 feet 2 inches.
(Similarly, a weight would be transcribed as 5 pounds 6 ounces, not 5 pound 6 ounces.)
 Use a hyphen between the numeral and the measurement in expressions used as adjectives,
except for metric units of measure (see Hyphens).
Examples:
There was a 3-inch laceration.
The patient had a 5-pound weight loss.
 Abbreviate all metric units of measure that follow numerals: cc (cubic centimeters), mcg
(micrograms), mL (milliliters), g (grams), kg (kilograms), etc. Do not abbreviate if no number is
dictated.
Examples:
Prostate measured 30 g and appeared normal.
The difference was less than a centimeter.
 Transcribe I’s and O’s as cc unless the author dictates mL. Only medication dosages are
changed to mL when dictated as cc; I&O is not medication.
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MEDICATIONS
Refer to the Dangerous Abbreviations list for further information on medication formatting.
Do not include a comma after the name of a drug if additional information is dictated for that
medication, e.g.,
1. Ecotrin 1 p.o. b.i.d. with meals.
2. Keflex 500 mg p.o. q.i.d. for 4 days.
3. Iron sulfate 325 mg p.o. b.i.d.
If the drug stands alone in the list, a comma is appropriate: Ecotrin, Keflex, iron sulfate 325 mg p.o.
b.i.d.
Use the complete spelling for drug names (not brief forms), e.g.,
 Dictated: nitro
 Transcribed: nitroglycerin
Trade Names
Abbreviations: When a drug trade name contains an abbreviation, e.g., Diovan HCT, do not expand
HCT to hydrochlorothiazide; it is part of the drug name. Just as Glucophage XR would never be
expanded to Glucophage Extra Strength, Diovan HCT would not be expanded. However, “pen VK”
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would be expanded to Penicillin VK as the latter is the correct drug name. Always check a reliable
pharmaceutical reference when determining whether or not the abbreviation is part of the trade name.
Capitalization: With registered and trademarked names, capitalize the initial letter only, e.g., Cypher
stent not CYPHER, Mobic 7.5 mg not MOBIC, Zithromax Z-Pak not Z-PAK.
Some proprietary names contain mixed case lettering, such as pHisoderm. Products with mixed case
lettering can be transcribed either with an initial capital letter or as the manufacturer’s name is shown on
the product. Always use an initial capital letter format for products with mixed case names at the
beginning of a sentence.
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NEOLOGISMS (COINED TERMS)
Neologisms, or newly invented words or phrases, are frequently encountered in dictation. Unless
account specific instructions direct otherwise, these are to be transcribed as dictated. It is generally
assumed that if an author dictates a term, the author wants that term transcribed. Some neologisms are
simply nouns (including proper nouns) that have been converted to verbs by adding a suffix; some are
terms that have been combined in an unorthodox fashion; and many are just invented terms that dictators
use to convey information with as few words as possible. Here are some examples: spasming, mucosy,
arousable, pupilloplasty, stridorous, ligaclipped (Ligaclip), satting (O2 sat), bovied (cauterized with
Bovie), prepped (widely accepted now but technically a neologism), cathed (catheterized),
hyperreflexivity, neuromusculoskeletal, genitoperineal, lumbalgia, crepitance, neuroforaminal.
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NUMBERS
 Spell out numbers when used as nouns. Examples:
o Do not proceed without one or the other.
o She will go with the two of them.
 Spell zero as a word when it stands alone. Example:
o The patient’s chances of recovery are zero.
 When the decimal point and zero following a whole number are dictated to emphasize the
preciseness of a measurement, e.g., of a pathology specimen or a laboratory value, transcribe
them as dictated. Do not, however, insert the decimal point and zero if they are not dictated.
o Dictated/transcribed: The specimen measured 4.8 x 2.0 x 3.4 mm.
but
o Dictated/transcribed: The specimen measured 4.8 x 2 x 3.4 mm.
o Exception: Do not include the trailing zero following a whole number in a drug dosage;
it could be misconstrued. Example: 75 mg, not 75.0 mg (could be construed as 750 mg).
See Dangerous Abbreviations list for details.
 For numbers less than 1, insert a zero before the decimal point. Example:
o D: .75 mg
T: 0.75 mg
o Exception: Bullet calibers (.22 not 0.22)
 Use a numeral for a fraction that precedes a noun when it is combined with a unit of measure
(i.e., compound modifier).
Example: 1/4-pound mass, 1/2-inch wound
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Page 15










Spell out and hyphenate fractions when they are used as adjectives.
Example: One-half normal saline was used.
Do not hyphenate fractions written out and used as nouns.
Examples:
One third of the calf was gangrenous.
The dosage was decreased by one half.
Use a numeral when a number is followed by a symbol.
Example: 5%, not five %
Use numerals to express mixed fractions. Do not replace dictated fractions with decimals.
Examples:
1-1/2 years (A hyphen must be used to separate a mixed fraction.)
Pregnancy at 35-3/7 weeks (not 35-3/7th weeks)
1/4 inch, not 0.25 inch
Use mixed fractions to express nonmetric units of measure.
Examples: 1-1/2 inches, 3-1/2 yards, 5-1/2-inch wound
Use decimals to express metric measurements.
Example: 1.5 cm
Psychiatric Diagnoses: Axis diagnoses are formatted using Roman numerals.
For Apgar scores, use numerals for ratings and spell out minutes. Rationale: This format draws
attention to the scores.
Example: The Apgar scores were 6 and 9 at one and five minutes.
Cranial nerves: Arabic numerals are preferred. Check account specific instructions.
Exponents: Because our customers do not allow the use of subscript or superscript, the
following formats are to be used:
Examples:
Dictated: The burn area was 4 centimeters squared.
Transcribe: The burn area was 4 sq cm.
Dictated: The specimen was calculated at 8 cubic millimeters.
Transcribe: The specimen was calculated at 8 cu mm.
Dictated: Adriamycin dose was 500 milligrams per meter squared.
Transcribe: Adriamycin dose was 500 mg/sq m.
Dictated: …eight to the third power.
Transcribed: …8 to the third power.
Dictated: …ten to the fifth power.
Transcribe: …10 to the fifth power.


Numerals 1-9: Numerals are preferred and are the required format for lab values, vital signs,
drug dosages, measurements, ages, or any other hard data.
Exception: Transcribe as words when used as nouns.
Ordinal numbers are used to indicate order or position in a series rather than quantity.
Expressing ordinals as numerals is preferred to writing them out:
o 1st, 2nd, 3rd, and 4th degree burns, NOT first, second, third, and fourth degree burns.
o Do not use ordinals if the term is not being used to indicate order or position in a series:
The patient is seen for a second opinion; the patient was seen for the first time.
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Page 16


o See Dates section above for the use of ordinals in dates.
Plural numbers: To express plural when using single-digit numbers, add an apostrophe s (’s).
To express plural when using multiple-digit numbers, add an s without an apostrophe.
Examples:
o 4 x 4’s
o 1970s
Beginning of sentence: If a dictated sentence begins with a numeral, it is acceptable to transcribe
as a numeral, transcribe as a word, or recast the sentence. Do not add an article (a, an, the) that
may make the sentence incorrect or awkward.
Examples:
Dictated: 20 prescribed.
Transcribe: Twenty prescribed.
Dictated: 3-0 Vicryl sutures were used to close the skin.
Acceptable: Sutures of 3-0 Vicryl were used to close the skin.
Acceptable: 3-0 Vicryl sutures were used to close the skin.
Dictated: One liter of crystalloid was given.
Acceptable: 1 L of crystalloid was given.
Acceptable: One liter of crystalloid was given.
Acceptable: Crystalloid 1 L was given.


When the numeral is a metric unit of measure and the numeral is spelled out, the unit of measure
must also be spelled out.
Dictated: 1 mg of Coumadin was given.
Transcribed: One milligram of Coumadin was given.
Adjacent numbers:
o When two numbers are adjacent, the unit of measure is a numeral and the amount is
spelled out.
 Example: Darvocet-N 50 one to two q.4-6 h. p.r.n. pain, but Percocet 2 tablets 3
times a day (numbers are not adjacent).
 Example: Novolin 70/30 eight units.
 The patient was given gentamicin x3. Thirty milliliters of fluid drained from the
wound on operative day 2.
o Exception: It is acceptable to add the word “of” for clarity in the following instance on a
non-verbatim account only: Dictated CO2 27; transcribe as CO2 of 27.
A comma is used with whole numbers of 5 or more digits unless a decimal is used. Four-digit
numbers do not need a comma.
Example:
24,500
15679.45
7400
Additional numeral formatting examples:
Dictated as:
six to eight
1 to 100,000 (ratio)
Acusis Standards Guide, rev. 11/25/2008
Transcribe as:
6-8 or 6 to 8
1:100,000
Page 17
Twenty-twenty vision
BP 120 over 80
grade two over six
A positive
Rh negative
three point five centimeters
point five centimeters
ten to twenty percent
four centimeters squared
five hundred milligrams per meter squared
two four by fours
20/20
120/80
2/6
A positive, not A+
Rh negative not Rh3.5 cm
0.5 cm
10% to 20%, not 10-20%
4 sq cm
500 mg/sq m
two 4 x 4’s
Return to Table of Contents
OBSTETRICS
There are 2 systems for describing a patient's obstetrical status. Both systems use Arabic numerals to
describe the patient's history.
GPA is an acronym that stands for gravida, para, and abortus. This system may be dictated using
individual letters or the entire term. The following is an example of an author's dictation for a female
patient who has had 3 pregnancies, 2 deliveries of viable offspring, and 1 miscarriage or abortion: G3,
P2, A1 (or Ab1) or gravida 3, para 2, abortus 1.
Note: Terms/abbreviations in the GPA system are separated by commas.
The TPAL system also describes a patient's obstetric history, but provides more information. This
acronym stands for term infants, premature infants, abortions, and living children. The following is an
example of an author's dictation using TPAL for a patient who had 3 term infants, 1 premature infant, no
miscarriages or abortions, and 4 living children: Obstetric History: 3-1-0-4.
Note: Terms in the TPAL system are not spelled out unless dictated in that fashion, and the numerals
are separated by hyphens, not commas.
Some authors combine the two systems. The following is an example of how one would transcribe a
dictation of combined GPA and TPAL systems.
D: Gravida four para three one zero four.
T: Gravida 4, para 3-1-0-4.
Return to Table of Contents
OFFENSIVE LANGUAGE/OBSCENITIES
There is no place in a patient’s medical record for offensive language, with the exception of direct
quotes when such are deemed necessary. If an author is documenting offensive remarks made by a
patient (a direct quote), those remarks are to be transcribed verbatim, enclosed in quotation marks, and
the Risk Management protocol followed. (See Risk Management section in this document and any
additions or exceptions in account specific instructions.) For those clients who require verbatim
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Page 18
transcription, follow the flagging instructions in the account specific instructions and notify your
supervisor.
Return to Table of Contents
PATIENT’S NAME IN TEXT
Follow account specific instructions regarding patient names.
Return to Table of Contents
PERCENT SYMBOL
See section called Symbols.
Return to Table of Contents
PLURALS
As a general rule, when forming plurals of words, do not use an apostrophe before the s, other than the
exceptions noted below. Examples:
 She is a mother with 2 daughters.
 The patient has a history of multiple MIs.
For plural numerals, add s without an apostrophe. Exception: With single numerals, add apostrophe s
(‘s). Examples:
 She is in her 20s.
 The wound was dressed with 4 x 4’s.
Use apostrophe s (’s) to form the plural of single letters. Examples:
 His mother told him to watch his p’s and q’s.
 Do routine checks on the patient’s I’s and O’s.
If an acronym or abbreviation is dictated in the plural form, add a lowercase “s” without an apostrophe.
Examples:
 serial CPKs
 a history of 3 MIs
Exception: Use apostrophe s (‘s) to form the plural of abbreviations that are lowercase. Example:
 The doctor ordered serials wbc’s.
 The nurse will routinely check I’s and O’s.
 The EKG showed flipped T’s.
Add s (no apostrophe) to form the plural of brief forms of words. Examples:
 His labs were checked.
 Her sats were monitored every hour.
To form the plural of a year, add s (without the apostrophe): He was well until the 1990s.
Return to Table of Contents
Acusis Standards Guide, rev. 11/25/2008
Page 19
POSSESSION
 To form the possessive form of a singular word, add apostrophe s (‘s): Examples:
o It was the caretaker’s day off.
o Her daughter’s cat ran away.
 To form the possessive form of a plural word, add s apostrophe (s’). Examples:
o There is a new television set in the doctors’ lounge.
 Nouns ending in s where only the final syllable ends in a sibilant show possession by adding
apostrophe s (‘s)/ Example:
o The fungus’s toxicity was ascertained.
 Nouns ending in s when each of the final 2 syllables end in a sibilant (s, x, z) show possession by
adding an apostrophe only. Examples:
o Jesus’ disciples
o physicians’ dictations.
 Hyphenated compound terms: Use apostrophe s (‘s) after the final word in hyphenated
compound terms. Example:
o daughter-in-law’s brother; son-in-law’s mother.
 Individual possession: When possession is not shared, show possession after each name.
Example:
o Dr. Smith’s and Dr. Freeman’s opinions differed.
 Joint possession: When possession is shared by 2 or more individuals, show possession after
final name only. Example:
o Doctors Smith and Freeman’s diagnosis was congestive heart failure.
 Possessive pronouns (e.g., hers, its, ours): Do not follow with an apostrophe.
 Units of time, measurement, or money: Use either apostrophe s (’s) or s apostrophe (s’)
depending upon usage. With the number 1, use an apostrophe s (‘s). Examples:
o 1 week’s time
o 1 dollar’s worth
For numbers greater than 1, use s apostrophe (s’). Examples:
o 22 weeks’ gestation
o 40 degrees’ flexion
 For the possessive form of proper nouns and eponyms, see section called Proper Nouns and
Eponyms.
Hint: If you can replace the possessive form with the preposition "of" without changing the meaning,
the apostrophe is correct, e.g.,
 30 degrees’ flexion =
 30 degrees of flexion


5 months’ pregnancy =
5 months of pregnancy


but not 5 months of pregnant
so not 5 months’ pregnant
Return to Table of Contents
PREFIXES
After most prefixes, do not use a hyphen to combine with the rest of the word.
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Page 20
Examples: micro-, non-, mid-, over-, pan-, pre-, post-, extra-. Refer to appropriate references,
e.g., those listed at the end of this document, for specific spellings.
Exception: non-insulin-dependent diabetes mellitus
Some words require a hyphen after a prefix because the absence of a hyphen would result in a word with
a different meaning.
Example: re-sort (to sort again), resort (alternative course of action)
Some prefixes are not combined with the next word and do not require a hyphen; utilize appropriate
references.
Example: The mid to distal 1/3 showed osteopenia.
Return to Table of Contents
PRO TIME
May either be expanded to prothrombin time, or if dictated in short form, may be written as pro time (2
words).
Return to Table of Contents
PROPER NOUNS AND EPONYMS
 Possessives: The possessive form of an eponym is not to be used unless account specific
instructions indicate otherwise.
Examples: Down syndrome, Raynaud disease.
Exception: When an eponym is not followed by a noun (e.g., disease following Raynaud), the
possessive form is preferred, e.g., Past medical history is significant for hypercholesterolemia
and Alzheimer’s. For her Crohn’s, the patient will be treated with Pentasa.
 Adjectives: The adjective forms of eponyms are never capitalized, e.g., parkinsonian or
pickwickian.
 Plurals: Do not use an apostrophe.
Examples: Kellys were used during the operation. The Smiths were invited to participate.
Titles: Consult appropriate references, but generally do not use periods.
Examples: MD, CMT, PhD, RHIT, DO, PA-C, DDS.
Return to Table of Contents
RANGES
Under most circumstances, use a hyphen or the word “to” to indicate a range. Do not use a colon.
Examples:
Followup appointment in 3-4 weeks OR followup appointment in 3 to 4 weeks.
A hyphen may be used when all of the following conditions are met:
o Neither value is a negative number (less than zero).
o Neither value includes a symbol (percent sign, virgule, etc.).
o Neither value contains a decimal, fraction, or colon.
o Neither value contains more than 3 digits.
o The phrases “from…to,” “between…and,” or “from…through” are not used.
Example: UA showed 10-12 WBCs per high power field.
Acusis Standards Guide, rev. 11/25/2008
Page 21
Cardiac murmur ranges: See Cardiology Terminology.
Cranial nerve ranges:
 Cranial nerves 2-12 were intact or cranial nerves 2 through 12 were intact.
Testing ranges:
 Pain scale 6/10 or 6 out of 10.
 Muscle strength 4/5 or 4 out of 5
 Reflexes 3+/4

If a minus (-) sign is used, which could be confused as a hyphen, do not use the virgule: 4- out
of 5
In most instances, when a range is combined with an over or out expression, spell out the expression.
 Blood pressure ranges:
o In a range of blood pressure readings, do not use a virgule in place of the word “over.”
Type out, as in 110-120 over 70-80 OR 110 to 120 over 70 to 80.
o Do not transcribe as 110-120/70-80 or 110/70 to 120/80.
o If “one teens to one twenties” is dictated as a blood pressure, transcribe as “one-teens to
120s.” Note: The definition of a range in the 110s is from 110.0 to 110.9.
 Testing ranges:
o Pain scale 1 to 2 out of 10 or 1/10 to 2/10, not 1-2/10
o Strength scale 4 to 4+ over 5 or 4/5 to 4+/5, not 4-4+/5.
Return to Table of Contents
RATIOS
Use a colon to separate numeric values. Do not use a virgule (slash).
Example:
Dictated: one to one hundred thousand
Transcribe 1:100,000
Use a virgule, a hyphen, or the word “to” in expressions that don’t contain a numeric value.
Examples:
male/female ratio
BUN to creatinine ratio
FEV-FVC ratio
Return to Table of Contents
RISK MANAGEMENT ISSUES
Any report containing dictated information that carries a potential risk to the patient, the author, or the
healthcare facility requires special handling. Leave a blank to replace any dictation that is deemed
inappropriate or offensive. This includes obscenities, racist remarks, profanity, derogatory language,
etc. In an effort to protect both the patient and the healthcare facility, any instance of a report which is
delivered with a blank for this reason must be reported to your supervisor, who in turn will report it to
the facility.
Acusis Standards Guide, rev. 11/25/2008
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Exception: Direct patient quotations that contain offensive language are to be transcribed
verbatim because the possibility exists that the record may be required for legal documentation.
All such reports are to be reported to your supervisor, who in turn will report it to the facility.
Check account specific instructions for the ability to place such a report on HOLD or for rerouting to
allow client handling before the report is made available for viewing in either paper or electronic form.
Return to Table of Contents
SCALES AND SCORES
Scales use Arabic numerals; most, but not all, scoring systems use Arabic numerals. Check appropriate
references to make sure the correct numbering system is used.
Examples:
Glasgow coma scale 5.
The Apgar scores were 6 and 9 at one and five minutes.
The patient had a LeFort II fracture.
Return to Table of Contents
SEMICOLONS
 A semicolon indicates a pause in text, stronger than a comma but not a complete stop, as
indicated by a period.
 Use a semicolon to separate two independent clauses when a conjunction (and, but, or) is not
used.
Example: Three ears are one too many; one ear is one too few.
 Use a semicolon to separate items in a series in which one or more of the items contain internal
commas.
Example: His medical history includes an MI, for which he received TPN; renal insufficiency;
gout; and hypercholesterolemia.
 Use a semicolon before a transitional expression when it joins two independent clauses.
Examples:
She had planned to have liposuction and a facelift; however, the plastic surgeon felt a tummy
tuck would be all that was necessary.
Cloning animals is not a good idea; moreover, cloning spouses, teachers, or politicians is not
either.
Note: Unlike periods, semicolons and colons are used outside quotation marks.
Return to Table of Contents
STAT
Brief form for the Latin statim meaning immediately. Do not capitalize or to follow with a period: We
ordered a stat EKG and serial cardiac enzymes.
Return to Table of Contents
Acusis Standards Guide, rev. 11/25/2008
Page 23
SUTURE SIZES
 The USP system sizes sutures ranging from 11-0 (smallest) through 7 (largest) and is described
as #1 through #7. Therefore, a size 1 suture is different from and larger than a size 1-0 suture.
 Brown-Sharp gauge stainless steel sutures range from #40 (smallest) through #20 (largest).
 Suture sizes are transcribed with Arabic numerals. Place the number symbol (#) before the size
if dictated. Do not express as all zeros, e.g., 00, 000, 0000.
Example:
Dictated: “Three oh Vicryl”
Transcribe: 3-0 Vicryl not 000 Vicryl
Dictated: “Number three oh Vicryl”
Transcribe: #3-0 Vicryl
Return to Table of Contents
SYMBOLS
Some customers’ software will allow the use of common symbols, e.g., ampersand (&), number symbol
(#), plus sign (+), percent symbol (%), and some will not allow their use. Review account specific
instructions before using any symbols in report text.
Ampersand (&) -- Symbol meaning and. Do not use the ampersand in drug dosages (see Dangerous
Abbreviations list). Can be used with certain single-letter abbreviations separated by and if permitted by
account specifics. Do not space before or after the ampersand. Do not use ampersand forms in operative
titles or diagnoses.
 D&C
 T&A


Dictated: Procedure Performed: T and A.
Transcribed: Procedure Performed: Tonsillectomy and adenoidectomy.
Greater than (>), less than (<) – Do not use these symbols; spell out. These symbols are often
mistaken for their opposite in meaning, and ISMP advises against their use.
 The patient’s performance on the trial is in the impaired range (289 seconds, less than the 1st
percentile).
 She weighed less than 100 pounds.
 The patient’s clotting time was greater than normal.
Percent symbol – Use the percent symbol (%) immediately following a numeral ONLY, with no space
between the numeral and the symbol. Spell out the word “percent” when no numeral immediately
precedes the term. Always use the word “to” in a range of percentages, never a hyphen, e.g., 50% to
75%. Always use the percent symbol with each number in the range. Example:
Dictated: ten to twenty percent
Transcribe: 10% to 20%
not
10 to 20%
Use decimals, not fractions, with percents: 0.5% not 1/2%.
Return to Table of Contents
Acusis Standards Guide, rev. 11/25/2008
Page 24
TEMPERATURE
 If the temperature scale name (Celsius, Fahrenheit, Kelvin) or abbreviation (C, F, K) is not
dictated, do not insert it.
 Spell out minus to indicate temperate less than zero: minus 48 degrees.
 If “tee max” is dictated (to mean maximum temperature), transcribe as T-max.
Return to Table of Contents
TIME/CLOCK REFERENCES
 Preferred format: a.m. and p.m.
 The word o’clock is dropped when reference is made to minutes past the hour, i.e., 4:30 not 4:30
o’clock. Check account specific instructions to verify client preference for standard or military
time.
 If military time is preferred, no colon is used, nor is the word o’clock. Military time is
transcribed as 4 digits based on 24 hourly divisions. Add zeroes before or after numerals, as
needed: 0130, 0600, 1500, 2330.
 When transcribing standard time on the hour, do not use :00, e.g., 4 p.m. not 4:00 p.m.
 Anatomic Positions: When anatomic locations are described using clock orientation, transcribe
o’clock only with numerals dictated on the hour. For minutes past the hour, drop the word
o’clock.
Examples:
The cervix was injected at the 3, 6, 9, and 12 o’clock positions.
A scleral incision was made at the 1:30 position.
Return to Table of Contents
TIMES (AS IN “TIMES TWO”)
“Times two” or “times three”: Substitute an x for the word “times” only when it is followed by a
numeral. Express as x3, lowercase x, no space between the x and the numeral. The expression “times”
as in “times two” may be transcribed appropriately as either x2 or as times 2. If the word “times” is
dictated, do not edit or substitute the word “for” for the word “times”; transcribe as the author dictates.
Example:
Dictated: Troponin I was negative times two.
Transcribe: Troponin I was negative x2.
Return to Table of Contents
VERBS
 Auxiliary verbs (forms of the verbs be, do, and have, as well as the modal auxiliary verbs can,
must, and may) are not to be transcribed following a heading or a subheading.
Example:
Dictated: Abdomen is soft; heart has regular rate and rhythm.
Transcribe: ABDOMEN: Soft. HEART: Regular rate and rhythm.
 Verb tense: Maintain the same tense (e.g., is/was, are/were) when transcribing a physical
examination paragraph or an operative report, unless an account requires strict verbatim
transcription.
Acusis Standards Guide, rev. 11/25/2008
Page 25
Return to Table of Contents
VERTEBRAE
 Express without a hyphen for a single vertebra, e.g., C6, L5.
 Repeat the letter before each vertebra in a list, e.g., L3, L4, and L5 not L3, 4, and 5.
 To indicate a disk space, a hyphen is used as follows: There was a degenerative disk at C5-6 and
at L5-S1. Note: Transcribe disk spaces as dictated. It is not necessary to repeat the same letter
before the second vertebra, but it may be transcribed if dictated.
 When expressing a range between vertebrae that are not adjacent and the author is not referring
to an intervertebral space, spell out the word “to” or “through”; do not hyphenate: The patient
had a fusion of C5 through C7. We plan to do a fusion of T9 to T11.
Return to Table of Contents
VIRGULE
 Do not use a virgule with medication dosages except when there are no numerals on either side
of the virgule, such as mL/tsp, mg/kg. Note: If the virgule is part of the drug name, the virgule
MUST be transcribed, e.g., Sinemet 10/100 or Advair 50/500.
 Do not use more than one virgule per expression (i.e., 5 mL/tsp per day, not 5 mL/tsp/day).
Exception: More than one virgule may be used in describing cancer therapy protocols, e.g.,
Adriamycin 20 mg/sq m/day IV on days 1, 15 and 29.
 Cardiac murmurs: See Cardiology section.
 Dates: A virgule (slash) is preferred, rather than a hyphen, in admission and discharge dates and
in dictated dates of procedures.
 Plus/Minus: Express as plus or minus or plus/minus, not +/- or ± , except in tables or test
results.
 Fractions: See Numbers section.
 Blood pressure values: See Ranges section.
Return to Table of Contents
YEARS
Use numerals to express specific years: 2005
Decades
 Plural: Add s (without the apostrophe) to form the numeric plural: He was well until the 1990s.
 Shortened: Use a preceding apostrophe in numeric expressions of decades of the century (’90s),
but do not use an apostrophe in expressions related to age (80s).
Examples:
I grew up in the ‘60s.
She is in her 40s.
 Special References: Spell out and capitalize special references to the decades.
Examples:
the Psychedelic Sixties
the Gay Nineties
Return to Table of Contents
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Page 26
APPENDICES
Three appendices follow:
 Appendix A: Unacceptable Terms
 Appendix B: Acceptable Terms
 Appendix C: Words That Sound Alike or Look Alike
As with the rest of this document and all Acusis policies concerning errors or style issues, your
account specific instructions are your first guideline.
The Acceptable Terms appendix applies to accounts that are not strictly verbatim. The abbreviations
contained in the Acceptable Terms list are not to be expanded out unless instructed to do so in account
specifics; we have merely provided the expansions for explanation purposes.
The Unacceptable Terms appendix is entirely in red font, which is designed to differentiate these from
the Acceptable Terms as a quick reference.
DISCLAIMER: The Acceptable and Unacceptable Terms lists are not meant to be all-inclusive; it is the
responsibility of the MT to research correct usage of abbreviations and terminology. For terms that are
not included here, consult other references such as the Stedman’s.
Acusis Standards Guide, rev. 11/25/2008
Page 27
Appendix A: Unacceptable Terms
Term
A&E
AC-DC, ac/dc
Explanation
accident and emergency (department)
bisexual
Admin
administer, administration
AL, A-line, art. line
alright
amnio
appy
ART
arterial line
nonstandard spelling of all right
amniocentesis
appendectomy
arterial (line)
art line
arterial line
B&O
B&W
BASO STIP
batt
BB
bd
BEEP
biochem
BK amp
bl
BO
Bod units
Brit
BS=BL
Bucky
BVDs
C diff
CB
chole
CIG
circ & sen
contrx
crepitance
CTXN
CV
D&A
DC
belladonna and opium
black and white (milk of magnesia and cascara extract)
basophilic stippling
battery
blow bottle, blue bloater (emphysema)
band
both end-expiratory pressures
biochemical, biochemistry
below-knee amputation
bland
body odor
Bodansky units
British
breath sounds equal bilaterally
(film in cassette in Potter-Bucky diaphragm)
underwear
C difficile
code blue
cholecystectomy
cigarettes
circulation and sensation
contractions
crepitus
contraction
curriculum vitae
dilatation and aspiration
dilatation and curettage, discharge, discontinue
DC’d
discharged, discontinued
DC'd
DDX, DDx
DECUB, decub
discontinued
differential diagnosis
ulcer, position
Acusis Standards Guide, rev. 11/25/2008
Page 28
Dex, D-stix
DG, Dg
Dextrostix
diagnosis
diag
DIE
diff diag
D-stix
Dx, dx
E
eosin
EPTFE, E-PTFE, e-PTFE
diagnosis
died in emergency (room)
differential diagnosis
Dextrostix
diagnosis
methylenedioxymethamphetamine (MDMA, Ecstasy)
eosin-methylene blue
expanded polytetrafluoroethylene
ex lap
exploratory laparotomy
fam doc
fam hist
family doctor
family history
FD
FHx
family doctor
family history
FLK
FLR
fluctuants
FTN
FUO
GB
funny-looking kid (leave blank or flag; risk management issue)
funny-looking rash
fluctuance
finger-to-nose (coordination, test)
fever of unknown origin
goofball (barbiturate pill)
GIGO
garbage in, garbage out
govt
government
GRAS
generally recognized as safe
H flu
HBGA
hep
het
Ho
horse
HPA
HPD
hypo
I or I
ICSHI
ICSI
IND
H influenzae
had it before, got it again
hepatitis
heterophil (antibody)
horse (slang for heroin)
(slang for heroin)
hypothalamic-pituitary axis
highly probably drunk
hypodermic
illness or injuries
intracytoplasmic sperm head injection
intracytoplasmic sperm injection
investigational new drug
IPM
JND
infant passive mitt (slang for hand)
just noticeable difference
Jx
KO'd
lam & fus
lami
junction
knocked out
laminectomy and fusion
laminotomy
Acusis Standards Guide, rev. 11/25/2008
Page 29
lap
laparoscopy, laparotomy
lap appy, lap-appy
lap chole
lap Nissen
lat
lat Rin
laparoscopic appendectomy
laparoscopic cholecystectomy
laparoscopic Nissen fundoplication
latissimus (dorsi)
lactated Ringer (solution)
lat, lats
latissimus (dorsi), latissimus (dorsi muscles)
LATCH
Lats
leukoesterase
m3
literature attached to charts
latissimus dorsi (muscle)
leukocyte esterase
cubic meter (see Numbers section above, subsection on
Exponents)
magnesium citrate
mag cit
mammo
melanotic
mammogram, mammography
Acceptable term when used correctly. Means “pertaining to the
presence of melanin”. NOT used to describe stools -- see melenic
under Acceptable Terms)
meth
mets
metz
methamphetamine, methedrine, methyl
metastases
Metzenbaum (scissors)
MgSO4
magnesium sulfate
MJ
MS, ms
marijuana
morphine sulfate
MSO4
morphine sulfate
MT
N
NARC, narc
narco
NEM
neuroforamen,
neuroforamina
nitro
Nitropaste, nitropaste
empty
negative
narcotic, narcotics officer (slang)
narcotics (hospital, officer, treatment center - slang)
no evidence of malignancy
neural foramen, neural foramina
NV
orthopaedic
nausea and vomiting
orthopedic
palp
Parietoperitoneum
palpate, palpable, palpation, palpitation
parietal peritoneum
pct
percent
PDQ
pen VK
pretty darn quick (slang)
Penicillin VK (Pen-Vee K was discontinued in 2002)
PEx
physical examination
PG
PHx
PIIS
pregnant
past history
posterior inferior iliac spine
nitroglycerin
nitroglycerin paste
Acusis Standards Guide, rev. 11/25/2008
Page 30
PM
post mortem (after death; PM is slang for this term)
PMHx
PN
po, P-O
POp, POP
PP
PR
past medical history
penicillin
postop
postop
pink puffer (sign of emphysema)
Panama red (variety of marijuana)
primip
primigravida
primip, PRIMP, PRLA
protime
psych
pt
q.h.
primipara
prothrombin time or pro time
psychiatric, psychiatry, psychologic, psychology
patient
every hour
qt
quiet
resus
resuscitation
roids
hemorrhoids
romied
ruled out for myocardial infarction
RR
Rx Phys
Rx’d
SC, sc
road rash (RR is slang for this term)
treating physician
treatment (prescribed)
SUCC
SUX
T3
tbl, tbs, tbsp
tic
TMTC
Subcutaneous or subcuticular; if unsure which is intended,
transcribe subcu or subcut (whichever is dictated).
small bowel obstruction
Subcutaneous or subcuticular; if unsure which is intended,
transcribe subcu or subcut (whichever is dictated).
succinylcholine
succinylcholine
Tylenol with Codeine (30 mg)
tablespoon
(diver)tic(ulum)
too many to count
TNTC
too numerous to count
TOP
trake or trach
triple A
ts, tsp
termination of pregnancy
tracheotomy, tracheostomy
AAA, abdominal aortic aneurysm
teaspoon
vanc
vax
vancomycin
vaccine, vaccination
vit cap
X-ed
XKO
yo, YO, y/o
vital capacity
crossed
not knocked out
-year-old, years old
small-bowel obstruction
SQ or subq
Acusis Standards Guide, rev. 11/25/2008
Page 31
Appendix B: Acceptable Terms
Term
Ab, AB
ABG
ACHOO
ACTH
ADHD
ADL and/or ADLs
AFib
AICD
AIDS
AIP
AKA
alk phos
allogeneic
Explanation
abortion or abortus
arterial blood gas
autosomal dominant compelling helioophthalmic outburst
(syndrome)
adrenocorticotropic hormone (corticotropin)
attention deficit hyperactivity disorder
activities of daily living
atrial fibrillation
Automatic implantable cardioverter-defibrillator
acquired immune deficiency syndrome
acute interstitial pneumonia
above-knee amputation
alkaline phosphatase
ALS
AMA
AMI
amyotrophic lateral sclerosis
against medical advice
acute myocardial infarction or anterior myocardial infarction
(check context for proper expansion)
amp
angioplastied
ampere or ampule (check context for proper expansion)
AP
AP/PA
ARDS
AROM
anteroposterior
anteroposterior/posteroanterior
adult respiratory distress syndrome
artificial rupture of membranes
arousable
arouseable
ASA
ASAP
ASCVD
ASHD
acetylsalicylic acid (aspirin)
as soon as possible
atherosclerotic cardiovascular disease
arteriosclerotic heart disease, atherosclerotic heart disease (check
context for proper expansion)
autopsied
AVSD
b.i.d., BID
atrioventricular septal defect
twice daily
ballottable, ballotte
band, stab
baso
BBB
bili
BiPAP
neutrophil
basophil
bundle branch block
bilirubin
bilevel positive airway pressure
Acusis Standards Guide, rev. 11/25/2008
Page 32
BKA
BM
below-knee amputation
bowel movement
bovied
BP
BPH
brady
brady’d
brady-tachy
BRAT
BRATT
BUN
BUS
C&S, C and S
CABG
CABGS
CAD
CAPD
blood pressure
benign prostatic hypertrophy/hyperplasia
bradycardia
bradycardia-tachycardia
bananas, rice cereal, applesauce, toast (diet)
bananas, rice cereal, applesauce, tea, toast (diet)
blood urea nitrogen
Bartholin, urethral, and Skene (glands)
culture and sensitivity
coronary artery bypass graft
coronary artery bypass graft surgery
coronary artery disease
continuous ambulatory peritoneal dialysis
cardiacwise or cardiac-wise
CAT
CAT scan
cath
cathed, cath’d
CBC, cbc
CC, cc
C-collar
CCU
CFIDS
CHD
chem panel
chemo
CHF
CHO
CJD
CMS
CMV
CN
COPD
CPAP
CPR
cryo’d
crystal meth
C-section
CSF
computed axial tomography
computed axial tomography scan
catheter, catheterization
catheterized
complete blood (cell) count
cubic centimeter
cervical collar
coronary care unit, critical care unit
chronic fatigue and immune dysfunction syndrome
congenital heart disease
blood chemistry profile
chemotherapy
congestive heart failure
carbohydrate
Creutzfeldt-Jakob disease
circulation, motion, sensation
cytomegalic (inclusion) virus
cranial nerves
chronic obstructive pulmonary disease
continuous positive airway pressure
cardiopulmonary resuscitation
methamphetamine
cesarean section
cerebrospinal fluid
Acusis Standards Guide, rev. 11/25/2008
Page 33
C-spine
CT
CTAP
CVA
CVAT
D&C, D and C
D5W
DCIS
DEA #
cervical spine
computerized tomography
clear to auscultation and percussion
cerebrovascular accident
costovertebral angle tenderness
dilatation and curettage
dextrose 5% in water (solution)
ductal carcinoma in situ
Drug Enforcement Agency number
desufflate
DIC
DIP
disseminated intravascular coagulation
distal interphalangeal (joint)
diuresed
DJD
DMARD
DNA
degenerative joint disease
disease-modifying antirheumatic drug
deoxyribonucleic acid
DNase, DNAse
DNI
DNR
DOA
DOB
DOE
do not intubate
do not resuscitate
dead on arrival
date of birth
dyspnea on exertion
dopplerable
DPT
DTP
DTR
DTs
DUI
DWI
EBT
EBV
ECG, EKG
ECHO
echo
ECMO
EDC
EDOC
EEG
ELCA
diphtheria, pertussis, and tetanus (vaccine)
diphtheria, tetanus toxoid, and acellular pertussis (vaccine)
deep tendon reflexes
delirium tremens
driving under the influence
driving while impaired, driving while intoxicated
external beam (photon) therapy
Epstein-Barr virus
electrocardiogram
enterocytopathogenic human orphan (virus)
echocardiogram
extracorporeal membrane oxygenation, extracorporeal membrane
oxygenator
expected date of confinement
estimated date of confinement
electroencephalogram
excimer laser coronary angioplasty
Email or e-mail
EMG
eo, eos
electromyelogram
eosinophil, eosinophils
Acusis Standards Guide, rev. 11/25/2008
Page 34
EOM
EOMI
ER
ERCP
ESP
ESRD
EST
EtOH
FADIR
FADIRE
FAST
fem-fem
fem-pop
fem-tib
fen-phen
FeSO4
FIGLU
FIO2
FISH
FIV
extraocular movement, extraocular muscle
extraocular movements intact, extraocular muscles intact
emergency room
endoscopic retrograde cholangiopancreatography
extrasensory perception
end-stage renal disease
electroshock therapy
ethyl alcohol (consumption, dependency)
flexion, adduction, internal rotation
flexion, adduction, internal rotation, and extension
Fourier-acquired steady-state technique
femoral-femoral (bypass)
femoral-popliteal (bypass)
femoral-tibial (bypass)
fenfluramine and phentermine
ferrous sulfate
formiminoglutamic acid (test)
fraction of inspired oxygen
fluorescent in situ hybridization
forced inspiratory volume
fluctuance
FNA
FSH
FVC
FYI
g
GAF
GC
GC/MS
GCS
GCSF, G-CSF
GERD
GI
GIFT
GLC/MS, GLCMS
GP
GRE
GSW
GTT
G-tube
GU
H&H, H/H, H and H
H&P, H and P
fine-needle aspiration
follicle-stimulating hormone
forced vital capacity
for your information
gram
global assessment of functioning
gonococcal (infection)
gas chromatography-mass spectrometry
Glasgow Coma Score, Glasgow Coma Scale
granulocyte colony-stimulating factor
gastroesophageal reflux disease
gastrointestinal
gamete intrafallopian transfer
gas-liquid chromatography/mass spectrometry
general practice, general practitioner, general purpose
gradient-recalled echo
gunshot wound
glucose tolerance test
gastrostomy tube
genitourinary
hemoglobin and hematocrit
history and physical (examination)
Acusis Standards Guide, rev. 11/25/2008
Page 35
HBOT
HCTZ
HCV
HDL
HELLP
HIV
HMO
Ho:YAG, Ho:YAG laser
HPA
HPF
HPI
HS, h.s.
hyperbaric oxygen therapy
hydrochlorothiazide
hepatitis C virus
high-density lipoprotein
hemolysis, elevated liver enzymes, and low platelet (count) or
hemolysis, elevated liver enzymes, low platelets.
human immunodeficiency virus
health maintenance organization
holmium:yttrium-aluminum-garnet
hypothalamic-pituitary-adrenal (axis)
high-power field
history of present illness
nightly
hyfrecated
hyperlachrymosis
hyperreflexic
I&D, I and D
ICD
ICP
ICU
IJ
INR
IU
IUD
IV
JVD
JVP
K
K wire, K-wire
KCl
KUB
KUS
lab
LABA
LAD
LADP
LAE
LASIK
LDL
LE
LEEP
incision and drainage
implantable cardioverter-defibrillator
intracranial pressure
intensive care unit
internal jugular (vein)
international normalized ratio
international unit
intrauterine (contraceptive) device
intravenous
jugular venous distention
jugular venous pressure
potassium (kalium)
Kirschner wire
(dictated "kay-cee-el") Transcribe as KCl not Kay Ciel unless
author spells it out.
kidneys, ureters, bladder
kidneys, ureters, and spleen
laboratory
laser-assisted balloon angioplasty
left anterior descending (coronary artery)
left acromiodorsoposterior (position of fetus)
long above-elbow (cast)
laser-assisted in situ keratomileusis
low-density lipoprotein
lupus erythematosus
loop electrocautery excision procedure, left end-expiratory
pressure
Acusis Standards Guide, rev. 11/25/2008
Page 36
LFT
lightheaded
LLE
LLLL
LLQ
LMP
LOC
LS
LSD
L-spine
liver function test
(no hyphen)
left lower extremity
lids, lashes, lacrimals, lymphatics
left lower quadrant
last menstrual period
loss of consciousness
lumbosacral
lysergic acid diethylamide
lumbar spine
lumbalgia
LUQ
LVH
lymph
lytes
max
MDMA
left upper quadrant
left ventricular hypertrophy
lymphocyte; lymphocytic
electrolytes; electrolyte panel
maximum
3,4-methylelenedioxymethamphetamine
medevac’d
melenic
mentating
marked by melena (e.g., dark, tarry stools)
MI
myocardial infarction
migrainosis
MMPI
modem
Minnesota Multiphasic Personality Inventory
modulator/demodulator
modemed
mono
monos
MOTT
MRI
MRSA
MS
Neuro, neuro
neuromuscularly
neuromusculoskeletal
NG
NICU
NIDDM
NIR
nonicteric
nonweightbearing
normoxemic
NPH
n.p.o.
mononucleosis, monocyte
monocytes
mycobacteria other than tubercle
magnetic resonance imaging
methicillin-resistant Staphylococcus aureus
multiple sclerosis
Neurology, neurology; neurologic
nasogastric
neonatal intensive care unit, newborn intensive care unit
non-insulin-dependent diabetes mellitus
near infrared
anicteric
neutral protamine Hagedorn (insulin)
nil per os; nothing by mouth
Acusis Standards Guide, rev. 11/25/2008
Page 37
NQMI
NS
NVD
O2
OJ
OK, okay
okayed
ORIF
OSA
Pap
path
PCA
PCN
PCP
PCV
PE
Peds, peds
PEG
PEG-J
PERL
PERLA
PERRLA
PIC
PICC
PIP
PKU
non-Q-wave myocardial infarction
normal saline
nausea, vomiting, diarrhea
oxygen
orange juice
(either form acceptable)
(not OK'd)
open reduction and internal fixation
obstructive sleep apnea
Papanicolaou (smear, test)
pathology
patient-controlled analgesia
penicillin
primary care physician
packed cell volume, polycythemia vera
physical examination, pulmonary embolism, physical education
Pediatrics, pediatrics
percutaneous endoscopic gastrostomy
percutaneous endoscopic gastrojejunostomy
pupils equal and react to light
pupils equal, reactive to light and accommodation
pupils equal, round, reactive to light and accommodation
peripherally inserted catheter
percutaneously (or peripherally) inserted central catheter
proximal interphalangeal (joint)
phenylketonuria
plateaued
PMD
PMH
PMI
PND
p.o.
pO2, pCO2
private (or personal) medical doctor
past medical history
point of maximal impulse
paroxysmal nocturnal dyspnea
per os; by mouth, orally
Capitalize first letter if at the beginning of a sentence.
polio
poly
poliomyelitis
polymorphonuclear (leukocyte); polymorphonuclear neutrophilic
granulocyte (leukocyte)
postoperative
marijuana
premature
postop
pot
preemie, premie
preop’d
prep
prepped
prepare, preparation
prepared
Acusis Standards Guide, rev. 11/25/2008
Page 38
p.r.n.
PSA
psych
PT
PTCA
PTT
PUD
pulse ox
PVC
q.2 h.
q.3 h.
q.4 h.
q.i.d.
RA
RBC
pro re nata; as needed
prostate-specific antigen
psychiatric, psychiatry, psychologic, psychology
prothrombin time
percutaneous transluminal coronary angioplasty
partial thromboplastin time
peptic ulcer disease
pulse oximetry
premature ventricular contraction
every 2 hours (note space between number and “h”)
every 3 hours (note space between number and “h”)
every 4 hours (note space between number and “h”)
quater in die; 4 times daily
rheumatoid arthritis
red blood cell
respiratorily
Rh
rhonchorous
RLE
ROM
ROS
Rhesus (factor)
right lower extremity
range of motion, right otitis media, rupture of membranes
review of systems
rousable
rouseable
RRR
RUE
RUQ
Rx
S7
SAB
SaO2
sat, satted, satting
SBE
SBO
scope
script
sed rate
sib, sibs
SIDS
SLUDGE
SMAC
SMZ-TMP, SMX-TMP
SNF
regular rate and rhythm
right upper extremity
right upper quadrant
prescription, prescription drug
summation gallop
spontaneous abortion
arterial oxygen saturation
saturation, saturated, saturating
subacute bacterial endocarditis
small bowel obstruction
endoscopic procedure or endoscopic instrument
prescription
sedimentation rate
sibling, siblings
sudden infant death syndrome
salivation, lacrimation, urination, defecation, gastrointestinal
distress and emesis
Sequential Multiple Analyzer Computer
sulfamethoxazole-trimethoprim
skilled nursing facility (dictated as "sniff")
Acusis Standards Guide, rev. 11/25/2008
Page 39
SOAP
SOB
subjective (data), objective (data), assessment, and plan
(problem-oriented record)
shortness of breath
spasming
SSRI
staph
stat
STD
steri-strip’d
strep
stye (plural: styes)
subcu, subcut
SVT
T&A, T and A
t.i.d.
tab
TAB
tach, tachy
tachy-brady
TAH
TAH-BSO, TAHBSO
TB
TEE
temp
TENS
THC
THORP
TIA
tib-fib
TKO
T-max
TMP-SMZ, TMP-SMX
TNM
TOPS
TPN
trach
TRISS
T-spine
TTE
TUNA
selective serotonin reuptake inhibitor
staphylococcus
statim; at once
sexually transmitted disease
(adjectival form of Steri-Strip)
streptococcus
hordeolum
subcutaneous
supraventricular tachycardia
tonsillectomy and adenoidectomy
ter in die; 3 times a day
tablet
therapeutic abortion
tachycardia
tachycardia-bradycardia
total abdominal hysterectomy
total abdominal hysterectomy and bilateral salpingooophorectomy
tuberculosis
transesophageal echocardiography
temperature
transcutaneous electrical nerve stimulator
tetrahydrocannabinol
titanium hollow-screw osseointegrating reconstruction plate
transient ischemic attack
tibia and fibula
to keep open (vein for IV)
maximum temperature; time of maximal concentration
trimethoprim-sulfamethoxazole
(primary) tumor, (regional lymph) node, (remote) metastases
(classification, staging)
Take Off Pounds Sensibly
total parenteral nutrition
tracheotomy, tracheostomy
Trauma and Injury Severity Score, Trauma-Related Injury
Severity Score
thoracic spine
transthoracic echocardiography
transurethral needle ablation
Acusis Standards Guide, rev. 11/25/2008
Page 40
TURP
URI
UTI
UVA
UVB
UVC
VBAC
VCU, VCUG
VD
VFib
water-pik’d
transurethral prostatectomy; transurethral resection of prostate
upper respiratory illness
urinary tract infection
ultraviolet A
ultraviolet B
ultraviolet C
vaginal birth after cesarean (section)
voiding cystourethrogram
venereal disease
ventricular fibrillation
(adjectival form of Water-Pik)
weightbearing
WNL
YTD
within normal limits
year to date
Acusis Standards Guide, rev. 11/25/2008
Page 41
Appendix C: Words That Sound Alike or Look Alike
Many words in the English language look alike or sound alike but have very different meanings. Below is a brief
list of some of the most commonly confused words. Please refer to the multiple resources available to help
determine which is the correct term to be used in each individual instance.
Some good reference books for words that sound alike include:
The Greg Reference Manual by William Sabin
The Book of Style for Medical Transcription
Pharmaceutical Word Book, Drake and Drake, published by W.B. Saunders (sound-alike drugs)
Apgar – score of a newborn’s condition; pulse, breathing, color, tone, and reflex irritability
APGAR – family screening acronym; adaptability, partnership, growth, affection, and resolve (not to be confused
with Apgar scoring of newborn physical status)
ascitic – pertaining to ascites
acidic – having characteristics of acid
acetic –resembling, containing, or producing acetic acid, or vinegar
abduction – moving away from the midline
adduction – drawing toward the midline
accede – to comply with or to give consent
exceed – to surpass or go beyond
accept – to take or receive
except – to exclude, take out or omit
aid – to give help or assistance
aide – one who gives help or assistance
advice (noun) – information or recommendation
advise (verb) – to recommend or give counsel
affect (verb) – to influence or change.
(noun) – a disposition or tendency. In medical usage, this term is used in psychology reports to refer to a
patient’s outward appearance of an inner mood: The patient’s affect was flat.
effect ( noun) – a result or impression: The effect of the earthquake was terrible.
(verb) – to bring about: This medication should effect a cure. (Effect is most often used as a noun.)
afferent – toward the center
efferent – outward away from the center
allude – make a vague reference
elude – escape or avoid
ante – occurring before
anti – against
antritis – inflammation of an antrum; maxillary sinusitis
enteritis – inflammation of the intestine; usually referring only to the small intestine
aphagia – refusal or inability to swallow
Acusis Standards Guide, rev. 11/25/2008
Page 42
aphasia – speech disorder or inability to comprehend spoken or written words
apposition – side by side; in medical terminology, it means the placing of things in juxtaposition or proximity,
such as bringing the edges of a wound together in apposition.
opposition – the act of being opposite, or the state of being set in opposite manner
avulsion – the ripping or tearing away of a part, either surgically or accidentally
evulsion – forcible extraction
awhile – adverb meaning for a short time
a while – noun meaning a short period of time
axis – a line about which a revolving body turns or would turn if it could rotate, a line around which specified
parts of the body are arranged; the 2nd cervical vertebra
access – a means of approaching, entering, exiting, communicating with, or making use of
excess – more than the usual, proper, or specified amount; superfluity
BNP – brain natriuretic peptide, or B-type natriuretic peptide, a hormone in the blood that indicates cardiac
function
BMP – basic metabolic panel, a group of 8 tests (or sometimes 7 tests) ordered as a screening to check for
conditions such as diabetes and kidney disease
buccal – adjacent to or pertaining to the cheek
buckle – an object to hold a belt together; to bend, crimp or crumple
bolus – a single, large amount of a medication given all at once
bulbus – a rounded mass or enlargement
bullous – relating to bullae
callous – hard like a callus
callus – hardened or thickened area of skin; meshwork of woven bone forming at the site of a healing fracture
carotid – pertaining to the principal artery of the neck (common carotid artery)
parotid – situated or occurring near the ear, as the parotid gland
cholic – an acid; relating to bile
colic – acute abdominal pain
cirrhosis – liver disease
xerosis – abnormal dryness
CNS – an abbreviation for the central nervous system, i.e., the brain and spinal cord
C&S – an abbreviation for culture and sensitivity testing used to identify pathogens
coarse – rough, opposite of fine: The patient’s hair was coarse. Coarse rales were heard in both lungs.
course – regular or natural progression: The disease must run its course.
conscience – guilt; knowledge or sense of right or wrong: His conscience bothered him after he stole the apple.
conscious – aware of one’s surroundings: The patient was awake and conscious.
dilation – the process of enlarging a passage or anastomosis
dilatation – the condition of being dilated or stretched beyond the normal dimension
Acusis Standards Guide, rev. 11/25/2008
Page 43
disc – an alternate spelling of disk
disk – the preferred spelling of this round, flat, regular and regularly condensed plate of material
discreet – showing good judgment in speech and actions
discrete – separate or distinct: There was a large, discrete mass in the abdomen.
diseased – ill, sick; a condition of the body that impairs health or vital function
deceased – no longer living; expired; recently dead
DNA – genetic material within chromosomes
D&E – dilation and extraction (obstetrical procedure)
dysphagia – difficulty swallowing
dysphasia – difficulty speaking
eczema – a type of dermatitis
exemia – loss of fluid from the blood vessels
effusion – the escape of fluid from anatomical vessels by rupture or exudation
infusion – the continuous slow introduction of a solution, especially into a vein
elicit – to bring out: Hopefully this will elicit a response.
illicit – illegal, such as illicit drugs
eminent – outstanding, as in character or performance; prominent
imminent – close in time, ready to take place
eversion – a turning inside out, e.g., ectropion; a turning outward, as of the sole of the foot or the eyelid
inversion – a turning inward or reversal of the normal relation of a part, e.g., visceral inversion is the right and left
transposition of the viscera
every day – occurring each day
everyday – ordinary, usual, as an everyday occurrence
exenterated – involving the surgical removal of inner organs; commonly used to indicate a radical excision of the
contents of a body cavity, such as the pelvis (the synonym of exenteration is evisceration)
exonerated – relieved of responsibility, obligation, or hardship; to clear from accusation or blame
eyelet – a small hole for receiving a rope or cord
islet – a cluster of cells; an island
fascicular – pertaining to a tract, bundle, or group of nerve fibers that are associated functionally
vesicular – containing or composed of vesicles, membranous fluid-filled pouch (cyst, vacuole, cell)
fetal – pertaining to a fetus
pedal – pertaining to the feet
H&P – history and physical
HNP – herniated nucleus pulposus
heterogeneous – consisting of dissimilar elements or ingredients
heterogenous – of foreign origin
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homogeneous – having a uniform structure or composition; the same kind or nature
homogenous – genetic term referring to descent from a common ancestral type
humeral – pertaining to the humerus
humoral – pertaining to the humors (any fluid or fluid-like substance of the human body)
ileum – distal portion of the colon (ileum = bowel)
ilium – superior portion of the hip bone ( ilium = hip)
insure – take out or issue insurance on something or someone
ensure – to make sure; to guarantee
installation – something installed for use; a military base or camp
instillation – to cause to enter drop by drop, as with medication
inter – a prefix meaning among or between
intra – a prefix meaning within
it’s – contraction for it is or it has
its – possessive pronoun indicating ownership: The dog raised its head.
laying – placing or putting, as in laying a book on the desk
lying – reclining on a surface, as in: The patient was lying in bed.
loop – an oval or circle formed by bending a wire, thread, vessel, etc.
loupe – a magnifying glass
lose – misplace; also, fail to win, as to lose a race
loose – not tight, as in loose closure or loose sutures; also, to free, as to loose a structure from adhesions
maybe – perhaps; implies that something might happen
may be – has the ability to happen; stronger than maybe. It implies that something can happen.
miotic – causing contraction of the pupil of the eye
myopic – nearsighted
mortis – Latin term meaning death, as in rigor mortis
mortise – the seat of the talus, formed by the union of the distal tibia and fibula at the ankle joint
mucous – pertaining to mucus
mucus – secretions of the mucous membranes
myasthenia – weakness of the muscles
myesthesia – sensation felt when a muscle contracts
nitrate – coronary vasodilators (nitrate = heart)
nitrite – nitrates converted to nitrite by bacteria in the urine (nitrite = urine)
osmolality – test of concentration of a solution, used to determine the concentration of urine or serum; results
expressed in milliosmoles per kilogram
osmolarity – concentration of an osmotic solution, e.g., urine or blood serum; expressed in osmoles per liter
osteal – bony
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ostial – pertaining to an ostium or opening
palpation – the act of feeling with the hand; the application of the fingers with light pressure to the surface of the
body to determine the consistency of the parts beneath in physical diagnosis, e.g., bimanual palpation
palpitation – to move frequently and rapidly; the subjective sensation of a rapid or irregular heartbeat
parameter – a characteristic, element, or attribute of a set of physical properties
perimeter – a line or strip around an area; boundary; the outer limits
paronychia – a skin infection around a finger or toenail
perionychia – inflammation of the epidermis overlying and in direct contact with the nail root or the sides of the
nail plate, forming the undersurface of the nail wall or nail folds (hidden nail skin/perionychium/epionychium)
perfuse – to force a fluid through (an organ or tissue) especially by way of the blood vessels
profuse – extravagant, bountiful
perfusion – the passage of blood or other fluid through the vessels of the body, or parts of it: There was good
perfusion of both lower extremities.
profusion – an abundance, pouring forth
peroneal – pertaining to the outer or fibular side of the leg
perineal – pertaining to the area between the anus and genitalia
peritoneal – pertaining to the peritoneum
perspective – one’s ideas
prospective – in the future; potential
plain – in radiology, those films taken without the injection of contrast material
plane – flat, level, or even; also, imaginary line dividing the body, as in frontal plane, sagittal plane, etc.
pleural – pertaining to the pleura surrounding each lung
plural – meaning more than one
pleuritis – inflammation of the pleura
pruritus – itching
pressor – tending to increase blood pressure
pressure – the application of force to something by direct contact, compression; the burden of physical or mental
distress
principal – a leader or the most important, consequential, or influential, i.e., principal diagnosis
principle – a rule or standard
prosthetic – an artificial device for a missing body part
prostatic – relating to the prostate gland
prostate – a gland found in males surrounding the neck of the bladder and urethra
prostrate – lying flat with the face down
radical – extreme, drastic or innovative; fundamental, basic: The patient had a radical mastectomy.
radicle – any one of the smallest branches of a vessel or nerve: The renal vein radicles were ligated.
regard – concerning, about, attention: With regard to the lab results, platelet count was abnormal.
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regards – esteem, respect, admiration: Give my regards to Mr. Jones.
saline – salty
xylene – a colorless, flammable liquid hydrocarbon used as a solvent
scleredema – unusual swelling of the facial area
scleroderma – chronic thickening and hardening of the skin
xeroderma – a mild form of ichthyosis, a genetic skin disorder causing abnormal scaling of the skin
shoddy – of poor quality or workmanship
shotty – resembling B-Bs or buckshot: The patient has numerous shotty nodes.
sight – vision; the ability to see
site – location: Clips were seen at the site of the aneurysm.
cite – to quote: The patient began to cite a list of his illnesses.
some time – an unspecified amount or period of time: Set aside some time to study.
sometime – at some unspecified time in the future: I will see you sometime tomorrow.
super – superior, better, excessive, more inclusive, e.g., supertherapeutic: therapeutic to a superlative degree,
displaying the strongest possible therapeutic qualities
supra – greater than, beyond, outside, transcending, e.g., supratherapeutic: beyond therapeutic, above or outside
of all therapeutic qualities
tachy – rapid, accelerated, as in tachycardia (rapid heart beat)
tacky – in poor taste, shabby, seedy, cheap, gaudy; somewhat sticky to the touch
their – belonging to them
there – in that place
they’re – contraction of they are
track – a path along which something moves or the mark left by its movement: I saw the lion’s track in the dust.
(Track is rarely used in medical dictation.)
tract – an elongated area, a passage or pathway: We then probed the sinus tract.
vesical – pertaining to the bladder
vesicle – a small sac containing fluid
weeks – plural of week: Our vacation this year is for 2 weeks.
week’s – possessive of week: He paid a week’s rent in advance.
weeks’ – possessive of weeks: Amniocentesis was performed at 22 weeks’ gestation.

HINT: If you can replace the possessive form with the preposition “of” without changing meaning, apostrophe use
is correct.
who’s – contraction of who is or who has
whose – possessive pronoun indicating ownership: The patient, whose surgery was scheduled, was admitted.
your – belonging to you
you’re – contraction of you are
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