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

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

Document formatting should begin flush with the left margin.

A heading of ASSESSMENT is part of a SOAP note.

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

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

Procedure Notes and Operative Notes are the same.

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

A Referral Note must include the vital signs.

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

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

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.

C-CDA recommends a specific template for Pathology Reports.

A Discharge Summary must include a PLAN OF TREATMENT section.

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

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

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

Subheadings should be in all capital letters.

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

All text should be typed flush to the left margin.

The CHIEF COMPLAINT section includes the clinician’s conclusion.

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

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

Use a double space after a period between sentences.

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

You should refer derogatory remarks to risk management.

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

Verbatim transcription means it is error-free.

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

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.

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

You must edit a run-on sentence.

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

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

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

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

Abbreviated units of measure should include a period.

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

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 the state and zip code.

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.

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.

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

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

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

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

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

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

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

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.

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

The first word of every sentence should be capitalized.

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.

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 general occupational titles when they precede personal names.

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

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.

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 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

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

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 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.

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 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 common organizational terms, such as department, division, or committee, when they are expressed as general references.

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.

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

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

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

Compound nouns are always expressed as separate words.

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

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

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

When referring to the common plural of genus, lowercase letters

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

Italicize foreign abbreviations, words, and phrases.

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

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

Spell out the English translation of Greek letters and capitalize.

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

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.”

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

Do not form a plural for units of measure.

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

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

Select the possessive form for personal pronouns.

Avoid using contractions in clinical records for personal possessive pronouns.

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

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