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.

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.

Document formatting should begin flush with the left margin.

A Referral Note must include the vital signs.

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

Procedure Notes and Operative Notes are the same.

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.

C-CDA recommends a specific template for Pathology Reports.

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

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.

A Discharge Summary must include a PLAN OF TREATMENT section.

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.

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.

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

All text should be typed flush to the left margin.

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

Use a double space after a period between sentences.

The CHIEF COMPLAINT section includes the clinician’s conclusion.

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.

Verbatim transcription means it is error-free.

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

You should refer derogatory remarks to risk management.

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

You must edit a run-on sentence.

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

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

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.

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

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

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.

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.

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

A semicolon should be used to separate two independent clauses.

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

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.

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.

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

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.

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

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.

Capitalize an independent question within a sentence.

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

The first word of every sentence should be capitalized.

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

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.

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

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 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.

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.

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 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 genus names used in plural and adjectival forms when used in the vernacular, or when they stand alone (without an epithet).

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

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.

Do not capitalize eponyms.

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

Compound nouns are always expressed as separate words.

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

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

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

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

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".

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

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

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.

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

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

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.

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

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

Select the possessive form for personal pronouns.

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

Avoid using contractions in clinical records for personal possessive pronouns.

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

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

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

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.

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

Never begin a sentence with an abbreviation.

Use periods with academic degrees or professional credentials

Expand contractions unless they occur in a direct quotation.

Do not use a period with abbreviations and brief forms.

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

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

Capitalize all letters in acronyms.

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

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

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

You may use ditto marks to indicate inches.

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.

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

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.

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

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

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

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

When writing roman numerals, do not use periods.

When expressing military time, you should use a colon.

You should place commas between words expressing a numerical value.

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

Use a hyphen when expressing compound fractions.

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

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