1. Transcribe as dictated.

2. Please use appropriate template provided.

3. Please use Arial font, size 10.
4. Please do not save your work on the template.
5. IGNORE any dictated medical record number (MRN).
6. IGNORE any dictated (not part of body of report) date of admission, date of service and date of discharge at
the beginning of the dictation EXCEPT for DISCHARGE NOTES.
7. IGNORE names of physicians. Replace the name of the physician with five (5) asterisks (*).
Example: D: Dr. Brad White
T: Dr. ***** *****
D: Dr. White
T: Dr. *****
8. Entries Put entries after the headings and/or subheadings NOT BELOW.
9. One paragraph space after entry of each main heading and/or subheading.
10. Patient name to be replaced with “the patient”.
Example: D: John Krasinski is an 80-year-old male with history of congestive heart failure.
T: The patient is an 80-year-old male with history of congestive heart failure.
11. Capitalize the first letter of departments or facilities even if the name of the facility is not dictated.
Example: D: This is an 86-year-old male who was brought to the emergency room for …
T: This is an 86-year-old male who was brought to the Emergency Room for …
12. Main headings must all be in UPPERCASE LETTERS and in bold format.
13. Subheadings must all be in UPPER CASE LETTERS but not in bold format.
14. ABBREVIATIONS: Do not expand abbreviations EXCEPT for abbreviated disease processes dictated in
Assessment/Impression/Conclusion.
15. Please use two (2) spaces after a period (.) and a colon (:).
16. Please use one (1) space after a comma or semicolon.
17. “End”, “check”, “end of dictation” signifies that the dictation has ended. Do not type this out.
18. Put four (4) paragraph spaces after the end of the report. The fifth (5th) paragraph space should be the line
where your line count (LC) is placed.
19. SAVING: Save your file as filename_yourinitials. Always Save As.
Example: 1234567_czm
20. DATES: D: one twenty seven
T: 01/27
D: March twenty seven two thousand and ten
T: 03/27/2010
D: twenty seventh of March
T: 27th of March
D: two two twelve
T: 02/02/2012
D: July of two thousand ten
T: July of 2010
D: two twenty three one two
T: 02/23/2012
21. NUMBERS: Expand numbers 0 to 9. Numbers 10 and up should be in Arabic form. Keep in mind the basic rules
for numbers.
22. ALLERGIES: Must be in all UPPERCASE LETTERS AND IN BOLD FORMAT.
23. MEDICATIONS: Number it if more than one medication is dictated. Do not use Auto numbering. Please refer to
medication reference/drug reference. Please follow rule on generic and branded medications.
24. ASSESSMENT/IMPRESSION/CONCLUSION: If you have more than one assessment or impression or
conclusion, please number it. Do not use Auto numbering. But if your assessment or impression or conclusion is
phrased in such a way that it is combined with a plan of care or recommendation, please type it out in paragraph
form (run-on).
25. LINE COUNT: To get your line count, click on Tools, choose Word Count on the dropdown menu. A box will
appear showing the total number of characters with spaces (word count). On your productivity sheet, enter
your word count on the WC column. After entering your word count, you will see your line count on the LC
column just beside it. (LC = WC/65). Please make sure that you fill in your line count after transcribing
WITHOUT FAIL.
26. SOAP NOTES: Entries should be in paragraph form (run-on).
27. The last hour of your shift should be dedicated to reviewing and scoring your file.
28. COMPARING AND MERGING: Discussed.

To be continued…