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.

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.

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

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

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

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

Procedure Notes and Operative Notes are the same.

A Referral Note must include the vital signs.

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

A Discharge Summary must include a PLAN OF TREATMENT section.

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

C-CDA recommends a specific template for Pathology Reports.

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

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

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.

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

All text should be typed flush to the left margin.

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

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

The CHIEF COMPLAINT section includes the clinician’s conclusion.

Use a double space after a period between sentences.

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 should refer derogatory remarks to risk management.

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

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.

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

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

Abbreviated units of measure should include a period.

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.

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

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.

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.

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 in expressions of military time.

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

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

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

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.”

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.

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.

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.

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

Capitalize an independent question within a sentence.

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 of an independent clause after a colon.

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

The first word of every sentence should 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 general occupational titles when they precede personal names.

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 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.

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

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

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 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

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 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 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.

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).

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

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

Compound nouns are always expressed as separate words.

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.

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

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

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

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

When referring to the common plural of genus, lowercase letters

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

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

Italicize foreign abbreviations, words, and phrases.

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

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

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.

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

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

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.

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.

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

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

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 contractions unless they occur in a direct quotation.

Use periods with academic degrees or professional credentials

Do not use a period with abbreviations and brief forms.

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

Never begin a sentence with an abbreviation.

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

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

Capitalize all letters in acronyms.

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

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

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

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).

You may use ditto marks to indicate inches.

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

Use the plus sign in tables or mathematical equations.

Greek letters should be written out using all lower case.

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

Add “s” with an apostrophe to form the plural of multiple-digit numbers, including years.

When expressing military time, you should use a colon.

When writing roman numerals, do not use periods.

When an ordinal number is used as a pronoun, you should not write it as a numeral.

You should place commas between words expressing a numerical value.

You should use fractions instead of decimals when nonmetric units are used.

Use a hyphen when expressing compound fractions.

When automatic word wrapping brings the unit of measure to the second line, carry the numeric value to the next line with it.

It is not acceptable to use arabic numerals at the beginning of a sentence when associated with a unit of measure, age, a 4-digit year, or immediately following a section heading.

When two distinct numbers are adjacent, write one of them as a word to prevent the reader from misreading the values.