Guidelines set by the client or the hospital to do their work in a certain specified format is called client specification. AAMT guidelines are the fundamental rules which every Medical Transcriptionist should know. AAMT guidelines gives you an overall information about specifications and/or rules of transcription. AAMT stands for American Association for Medical Transcription. AAMT guidelines are standard rules, whereas client specifications are the rules set by the client and/or hospital. What you need to do is know the AAMT guidelines first and simply follow the client specifications. Here the seriousness of the job is that you need to strictly follow client specifications.
Below are some important client specifications and how to avoid specification errors.
Page setup consists of page margins (Top, Bottom, Left, Right margins); Header and Footer; Font (Type and Size); Text Alignment (Left or Justified). You need not worry about this if templates are provided by the client; simply use the template. Your file may be 100% accurate, but if the page setup is wrong then it's a major mistake. Page setup errors occur when you copy and paste your template into a new document. Instead of copying the template into a new document, simply do Alt + F + A (save as) of the template. This page setup specification is applicable to MS Word and is useful to those who are on offline work.
Above point is not applicable to Online Platforms.
The most commonly used specification to put a blank is underscore. This may vary according to the client or hospital you are working for. If the blank is said to be five underscores or whatever the client wants then it should be strictly applied in the report. To avoid this specification error you can add the specification to the AutoCorrect. This is applicable to offlien work and MS Word. Online platforms have automated time stamps with shortcut keys to put a blank.
General rule for number usage in the rpeort is that numbers from 1 to 9 are keyed in as words (one to nine) and numbers from 10 and above are keyed in as numbers. This rule changes depending on the client. Some clients may want numbers from 1 to 9 also to be keyed in as numbers. You need to be a bit careful about this. To avoid this specification error, you need to remember this specification whenever you come across a number in the report. This specification is applicable to both offline and online work.
The most common date formats used in medical report are:
October 3, 1976 if it is a full date.
If only month and year are dictated then it can be 10/76 (or) 10/1976 (or)
October 1976. You can add this specification to the AutoCorrect and change dates as dictated.
This specification changes depending on the client. General rule is that the Allergies are Bolded. The below mentioned examples are just to give you an idea, and this may differ from client to client.
Bolded and Capitalized
ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN.
ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN.
Only Allergy Bolded
ALLERGIES: The patient is allergic to
This specification may or may not be mentioned sometimes mentioned in provided specifications document. You need to make sure with your system administrator to avoid this specification error. This specification is not applicable to online platforms.
Patient Name Usage
Clients are very specific about the usage of patient name in the report. Some clients want the patient name to be keyed in as dictated whereas some clients want to key in "the patient" whenever you come across the patient's name in the report. Some clients provide patient list whereas some may not. If patient list was not provided then in such case the client may ask you to type the patient's name phonetically whenever you come across in the report. This specification may or may not be mentioned in the specification document; get in touch with your account head for clarification to avoid this specification error.
Client may ask you to go strictly according to the template and not to add or make any changes to the side headings that are already there in the template. Some clients may ask you to add side headings as dictates and can change side headings of the template as dictated. Sometimes, client's provided templates may not have any side headings, but they may ask you to add side headings as dictated by the physician. To avoid this specification error, you need to keep this in mind while transcribing the report.
This specification also varies from client to client. Some clients want the medications to be listed if they are more than one in number. If listed, then you should know if it is autonumbering or number followed by a period and two spaces. Some clients prefer medications to be typed in a paragraph separated by commas. You need to know this and remember this whenever you come across medications to avoid this specification error.
Most of the online platforms do not have auto numbering and they follow strict two spaces after numbers in a numbered list.
Online platforms also avoid using special characters or symbols like &, @, $, *, etc.
The above-mentioned specifications are just to give you a brief idea on how to understand and apply a specification in a medical report. Keep the specifications document open while transcribing the report to avoid any specification errors.
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