The PAST MEDICAL HISTORY section records the patient’s past complaints, problems, and diagnoses.

Document formatting should begin flush with the left margin.

According to the Joint Commission, the timeframe for completing a History and Physical report for admission is 48 hours.

Drug allergies recorded in the ALLERGIES AND INTOLERANCES section should be bold and all capital letters.

A heading of ASSESSMENT is part of a SOAP note.

History and Physical reports must be completed within twenty-four hours of hospital admission.

There are reference standards for the order of headings in an Operative Note.

Procedure Notes and Operative Notes are the same.

A Referral Note must include the vital signs.

The established regulation on a TAT for a Consultation Note is twelve hours.

A Discharge Summary must include a PLAN OF TREATMENT section.

C-CDA recommends a specific template for Pathology Reports.

A Transfer Summary may be used instead of a Discharge Summary.

An electronic health record must be able to generate and exchange a Continuity of Care Document.

In a Diagnostic Imaging Report, the only required heading is CONCLUSIONS.

A PREOPERATIVE DIAGNOSIS section includes the surgeon’s opinion on a diagnosis that will be confirmed by a procedure.

A DISCHARGE DIAGNOSIS section will include the problems and diagnoses that occurred during the hospitalization.

Subheadings should be in all capital letters.

A VITAL SIGNS section may include the patient’s height and weight.

A serif font is preferred for medical documentation for readability reasons.

The patient’s marital status is included in a GENERAL STATUS section.

Use a double space after a period between sentences.

History and physical exams should be performed within twenty-four hours of inpatient admission.

All text should be typed flush to the left margin.

The CHIEF COMPLAINT section includes the clinician’s conclusion.

You may edit a medical record to correct translation errors made by speech recognition.

Verbatim transcription means it is error-free.

You should refer derogatory remarks to risk management.

Flagging a document that needs to be reviewed by risk management is acceptable.

You should not edit syntax to maintain the dictator’s style.

You should edit pronouns in the record to align with the patient’s gender.

You should always correct dictated punctuation errors that do not affect meaning or readability.

You must edit a run-on sentence.

When a portion of dictation is missing, you should leave a blank and flag.

Derogatory remarks about a patient’s family member should be left as dictated and flagged to Risk Management for review.

Abbreviated units of measure should include a period.

A comma should be used to separate two or more adjectives modifying the same noun.

Abbreviations in treatment and drug dosing instructions should include a period.

When asking a question within a direct quote, the question mark should be inside the end quotation marks.

A comma should be used to separate groups of three numerals in five digits or more but omitted if the number includes a decimal

Use a colon followed by one space to separate the heading from a content set on the same line.

Commas are not used to separate values of a single panel or test.

Do not use a comma to separate a person’s name from a credential.

A comma should not be used to separate the day of the month from the year.

Do not use a comma to separate the state and zip code.

A colon should not be used in expressions of military time.

A hyphen should be used for all compound modifiers when they precede or modify a noun or pronoun.

A colon should not be used before a list or series of clauses.

Use a hyphen when fractions are expressed as words.

A semicolon should be used to separate two independent clauses.

You can use a virgule where two terms are of equal weight in the expression.

Use a hyphen with all disease-entity modifiers that precede a noun.

A hyphen should not be used with a prefix that precedes a proper noun.

Hyphens should be used to create compound modifiers formed with one-word modifiers and prefixes.

A virgule may be used when expressing duality, taking the place of “or” or “and.”

Lower-case letters should be used to begin quotations if they represent an independent clause.

Punctuation marks should be inside the closing quotation marks in direct quotes.

A virgule should be used when expressing visual acuity with Arabic numerals.

When using an exclamation point as part of a direct quote, the exclamation point should be outside the quotation marks.

Double quotation marks should be used to represent feet and inches in dimensional expression.

Do not capitalize the first word after a colon if it is a proper noun or another word that is ordinarily capitalized.

Capitalize an independent question within a sentence.

Capitalize the first word of an independent clause after a colon.

The first word of every sentence should be capitalized.

Do not capitalize the first word after a colon when the material preceding the colon is a short introductory word, such as Note, Caution, or Wanted.

Capitalize the first word following the opening dash or parenthesis of a parenthetical question unless it is a proper noun or another word that is ordinarily capitalized.

Capitalize all personal, executive, professional, civic, military, and religious titles that come immediately before the person’s name or that are used as part of their name or replacing their first name.

Items in a list or an outline, even when items in the list represent single words, phrases, or clauses, should not be capitalized.

Capitalize the first word following the colon when used to set off a heading or subheading, especially in the case of the Review of Systems and Physical Exam.

Capitalize general occupational titles when they precede personal names.

Capitalize credentials that are spelled out when they are generally referenced in a sentence unless they follow a personal name as a formal title.

Capitalize all words in literary and artistic titles except articles (the, an, a), short conjunctions, and short prepositions unless they occur as the first or last word of

Do not capitalize general references to legal terms, such as power of attorney, living will,, unless the full formal name of the low or document is referenced.

Family titles (e.g., mother, father, mom, dad) should not be capitalized when preceded by an article (explicit or implied) or a possessive pronoun.

Capitalize the word grade when referring to grade levels only when a number follows it but not when a number precedes it.

Capitalize the O’ prefix in names that contain it but not the letter that follows the apostrophe.

Capitalize the trademark or unique name of a product and use lowercase for the descriptive terms.

Capitalize the abbreviated forms of company, corporation, incorporated, and limited when the business name incorporates those abbreviations in its formal name or title.

Capitalize the abbreviated forms of company, corporation, incorporated, and limited when the business name incorporates those abbreviations in its formal name or title.

Do not capitalize proper nouns and official names of a person, place, or thing.

Do not capitalize common organizational terms, such as department, division, or committee, when they are expressed as general references.

Do not capitalize eponyms.

Capitalize the word city only when it is part of the name of the city, or in the nickname of that city.

Do not capitalize genus names used in plural and adjectival forms when used in the vernacular, or when they stand alone (without an epithet).

Capitalize the names of races, languages, nationalities, ethnicities, tribes, political parties, religions, and religious denominations.