A heading of ASSESSMENT is part of a SOAP note.

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

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

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

Document formatting should begin flush with the left margin.

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

A Referral Note must include the vital signs.

Procedure Notes and Operative Notes are the same.

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

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

C-CDA recommends a specific template for Pathology Reports.

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

A Discharge Summary must include a PLAN OF TREATMENT section.

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

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

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

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

Subheadings should be in all capital letters.

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.

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

Use a double space after a period between sentences.

The CHIEF COMPLAINT section includes the clinician’s conclusion.

You should refer derogatory remarks to risk management.

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

Verbatim transcription means it is error-free.

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

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

You must edit a run-on sentence.

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.

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.

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

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

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

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.

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

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.

Use a hyphen when fractions are expressed as words.

A semicolon should be used to separate two independent clauses.

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

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

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

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

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

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

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.

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

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

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

Capitalize an independent question within a sentence.

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.

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

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 general occupational titles when they precede personal names.

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 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.

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

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

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

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

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

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

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

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

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 eponyms.

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

There are words that retain the same form in the singular and plural.

Add an “s” to most nouns in the singular to form the plural when preceded by a vowel.

Compound nouns are always expressed as separate words.

Nouns whose plurals are formed in unusual ways are considered regular forms.

Add an “es” to nouns ending in a “y” when preceded by a consonant.

When referring to the common plural of genus, lowercase letters

Pluralize a single-digit number by adding only an “s".

When you pluralize a proper noun, always retain the original spelling.

For hyphenated compounds, pluralize the chief noun of the compound.

Do not form plurals for abbreviations by adding “s” to the singular abbreviation form.

Spell out the English translation of Greek letters and capitalize.

Express possession of a singular noun that does not end in “s” by adding an apostrophe plus “s” to the noun.

Italicize foreign abbreviations, words, and phrases.

Express possession of compound nouns by adding an apostrophe at the end.

When forming a plural for a Latin or Greek medical term, change “-en” to “-ina."

Do not form plurals for abbreviations by adding “s” to the singular abbreviation form.

Latin or Greek medical terms ending in “-us” are the same in singular and plural forms.

Do not form a plural for units of measure.

When forming a plural for Latin or Greek medical terms, change “-um” to “-a.”

When forming a plural for Latin or Greek medical terms, change “-is” to “-es.”

Select the possessive form for personal pronouns.

Express possession for nouns that end in “s” or “es” by adding an apostrophe before the “s.”

Avoid using contractions in clinical records for personal possessive pronouns.

Express possession of compound nouns by adding an apostrophe at the end.

Express possession of singular abbreviations by adding an “s” to the end of the abbreviation.

A brief form is a form of the word but includes syllables from the whole word.

An initialism is an abbreviation formed from the initial letters of each successive word in a compound term and is pronounced as a word.

An acronym is an abbreviation formed from the initial letters of each successive word in a compound term and is pronounced as a word.

Expand a dictated abbreviation if it is related to a diagnosis used in a postoperative report.

Use an abbreviation whenever possible, even when the term or phrase is dictated in full.

Abbreviate state and territory names when they are preceded by a city, state, or territory name.

Never begin a sentence with an abbreviation.

Expand contractions unless they occur in a direct quotation.

Do not use a period with abbreviations and brief forms.

Use periods with academic degrees or professional credentials

Do not use a space to separate a number from an alphabetic symbol.

Use a lowercase “s” when forming a plural for an abbreviation, acronym, or brief form.

AHDI recommends editing dangerous abbreviations to the preferred term or phrase.

Capitalize all letters in acronyms.

Do not use a space to separate a number from a nonalphabetic symbol.

You may use ditto marks to indicate inches.

Ditto marks should not be used to indicate the same word or phrase.

Do not use the pound sign to indicate the word pound(s).

The degree symbol is a disallowed character and should always be spelled out.

You may use the percent sign with arabic numerals at the beginning of a sentence.

You may use a single apostrophe as the symbol for prime.

Use a pound sign before a house number in the street address.

Use the plus sign in tables or mathematical equations.

Greek letters should be written out using all lower case.

Use a lower case “x” to express area, volume, and dimension.