MT Grammar, Punctuation & Editing Standards 3 — Questions and Answers
Question 1: A physician dictates 'The patient is a 45 year old female.' How should age be transcribed in a medical report?
- The patient is a forty-five year old female.
- The patient is a 45 year-old female.
- The patient is a 45-year-old female. (Correct answer)
- The patient is a 45 year old female.
Correct answer: The patient is a 45-year-old female.
Ages used as compound modifiers before a noun are hyphenated; '45-year-old' requires all three hyphens.
Question 2: Which of the following is the correct transcription of a blood pressure reading?
- Blood pressure was 120 over 80.
- Blood pressure was 120/80. (Correct answer)
- Blood pressure was 120:80.
- Blood pressure was 120-80.
Correct answer: Blood pressure was 120/80.
Blood pressure values are transcribed with a forward slash separating systolic from diastolic values (e.g., 120/80).
Question 3: When should brackets [ ] be used in a medical transcription document?
- To indicate optional text added by the transcriptionist for clarity
- To enclose a parenthetical remark from the dictator
- To flag words that are unclear or questionable in the dictation (Correct answer)
- To separate items in a complex list
Correct answer: To flag words that are unclear or questionable in the dictation
Brackets are used in medical transcription to flag unclear, inaudible, or questionable words for physician review.
Question 4: Which sentence demonstrates correct use of the dash (em dash) in medical transcription?
- The biopsy results - pending - will determine the next step.
- The biopsy results—pending—will determine the next step. (Correct answer)
- The biopsy results – pending – will determine the next step.
- The biopsy results (pending) will determine the next step.
Correct answer: The biopsy results—pending—will determine the next step.
Em dashes (—) with no spaces around them are used to set off parenthetical information for strong emphasis in formal medical documents.
Question 5: The dictator says 'pre-operative orders.' Which transcription is correct per current BOS style?
- pre-operative orders
- preoperative orders (Correct answer)
- Pre Operative orders
- pre operative orders
Correct answer: preoperative orders
The prefix 'pre' is generally joined without a hyphen to the root word in standard medical terminology; 'preoperative' is the preferred closed form.
Question 6: A report contains the sentence: 'She takes aspirin, lisinopril, and atorvastatin.' The physician adds a dictated note: 'Also metoprolol which I forgot.' How should the MT handle this?
- Add metoprolol to the list exactly as dictated at the end of the sentence
- Insert metoprolol alphabetically into the medication list and flag the edit
- Add metoprolol to the list in the order dictated and flag the insertion per facility policy (Correct answer)
- Refuse to edit the list without a written addendum
Correct answer: Add metoprolol to the list in the order dictated and flag the insertion per facility policy
The MT should add the medication in the order dictated and flag or note the addition per facility/client policy to maintain a clear audit trail.
Question 7: Which of the following correctly transcribes a time reference in a medical report?
- The patient arrived at 3:00 P.M.
- The patient arrived at 3:00 p.m. (Correct answer)
- The patient arrived at 3:00 PM
- The patient arrived at 3:00 pm.
Correct answer: The patient arrived at 3:00 p.m.
AAMT/BOS style specifies lowercase 'a.m.' and 'p.m.' with periods, used after a clock time with a colon separating hours and minutes.
MT Grammar, Punctuation & Editing Standards 3
A physician dictates 'The patient is a 45 year old female.' How should age be transcribed in a medical report?