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Guidelines
Also Known As MedQuist DocQscribe Guidelines
Version 3.0
GENERAL INFORMATION ___________________________________________________________________ 4
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General Information
This document details MedQuist's standards for producing transcribed documents in
DocQscribe. These standards have been developed with the intent of simplifying the process
and gaining efficiency while creating high-quality medical reports.
DocQmanage Client Profiles will list the EXCEPTIONS or, in some cases, preferences of the
individual client. Therefore, the Client Profile supersedes those applicable sections of this
document. These guidelines should be used on 100% of MedQuist clients as a baseline with
individual Client Profiles acting as a supplement to this document.
Any questions or concerns about the content of this document or how to apply these standards
while transcribing in DocQscribe should be sent to mtquestions@medquist.com.
Note: Any previous MedQuist guidelines are obsolete outside of this document.
MedQuist DocQscribe Standards and DQS Guidelines, MedQuist DQS Guidelines, MedQuist
Guidelines best practices for transcription
Demographics Screen ADT screen, Ctrl + D
ADT demographics ADT, demographics, ADT definition, ADT field,
demographic field, Ctrl + D field
Available Names database physicians database, dictator database
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Prohibited Abbreviations and Special
Characters
Prohibited Abbreviations
Below is The Joint Commission (TJC -- previously JCAHO) Official Do Not Use List., The below list is the
MedQuist standard for prohibited abbreviations.
_________________________________________________________________________
Note: If a client requires additional prohibited abbreviations, or has their own list, specifics
will be noted in the client profile. Any previous MedQuist style guides, abbreviations lists,
etc., are obsolete outside of this document and the client profile (including BOS2 Dangerous Abbreviations).
__________________________________________________________________________
Special Characters
-The following special characters are prohibited from being utilized in DocQscribe:
&
subscripts
superscripts
@.
degree sign
\
~
^
|
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Client Overview
References
MedQuist DocQscribe Standards and Guidelines
Client Profile
MedQuist National Quality Program
AAMT Book of Style for Medical Transcription, Second Edition (AAMT is now known as AHDI)
Report Format
Transcribe as dictated correcting only for grammar and client's format preferences.
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Numbered Lists and Sub lists Format
Create the numbered list flush left by typing the numeral, period, two spaces, and then the text. Do not
use tab or indent. Do not insert blank lines between numbered items. Sub lists (letters) are only to be
incorporated if dictated.
Use paragraph form unless dictator indicates a list format (i.e., numbers or states “next” or “new line”).
Always number a list, unless profile states otherwise. Do not number just one item.
Expansions
DocQscribe expansions should be limited to 1,000 characters per expansion. Lengthy expansions are not
recommended. Do not include standards in personal expansions because updates will be missed,
DocQscribe allows users to create an abbreviation in the expansion file which links to the desired
standard. See DocQscribe User Help Guide in DocQscribe.
NOTE: Using an expansion does not release the MT from matching the transcription to the dictation.
Use with caution.
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Courtesy or Carbon Copies
- Only as dictated.
- Select from the available names list to populate.
- If CC name is clearly dictated but not found in CC list, create "new" entry and enter information
in the appropriate fields. Any dictated fax numbers should be entered in the last name field after
the name: "Smith, 555-1222"
- If CC name is not understood and phonetic spelling not possible, create "new" entry and put
"Dr.____" using 10 underscores, in last name field. Ensure QA/QC Note states "cc unintelligible".
- If CC stated as “Dr. John Smith” do not assume MD. Enter First Name as “Dr. John” and Last
Name as “Smith.”
- If last name only is given and not in database, or you cannot choose between multiple entries in
the database, create a "new” entry. Enter as Last Name: Dr. Smith.
Date Format
In body of document, transcribe dates as dictated inserting appropriate punctuation and use ordinals
where appropriate.
Spacing
- Insert 2 spaces after a colon.
- Insert 2 spaces after periods that end sentences.
- Insert 2 hard returns (Enter key) between paragraphs (one at the end of the sentence and an
extra return to create 1 blank line between paragraphs).
- Insert 1 space before and/or after a dash (does not apply to hyphens).
Allergies
Heading and transcribed mixed case.
</ALLERGIES/>
Patient had no known allergies.
Then begin the next section with red-tagged heading to terminate ALLERGIES special formatting.
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Axis Format
Stacked, left justified with mixed case subheadings, using roman numerals.
</DIAGNOSES/>
Axis I: Major depressive disorder, single episode, severe, without psychotic features. Alcohol abuse.
Axis II: Dependent personality disorder.
Axis III: Text.
Axis IV: Text.
Axis V: Text.
Standards Protocol
All heading tags included in a standard are to remain in the body of the document even if not dictated. If
there is nothing dictated for a specific heading, remove the @@ code only.
Insert and utilize any standard as directed by dictator. Mandatory standards will be noted in either the
work type specific instructions section or dictator specific instructions section of the client profile.
</REPORT TITLE/>
Cardiology Consultation (no period here)
Note: Please see the Appendix Section of this document for further detailed information
Scenario 2 - Work Type entered does not match information being dictated and is a work type you
transcribe
-Change to work type that matches information being dictated. Transcribe as dictated following work
type guidelines.
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Scenario 3 - Work Type entered does not match information being dictated and is not a work type you
transcribe.
-Change to the work type that matches information being dictated. From the DocQscribe edit screen
choose Break in the upper right hand corner. Breaking the job in this manner will save the work type
change and route the job appropriately.
Scenario 4 - Work Type comes in as Zinvalid and correct work type is available in work type list
-Change to work type that matches information being dictated. Transcribe as dictated following work
type guidelines or refer to scenario 3 above to break job for rerouting if you do not transcribe this
work type.
Scenario 5 - Work Type comes in as Zinvalid and correct work type is not available in work type list or
cannot be determined based on information dictated
-Leave work type as populated and transcribe as dictated. Enter a QA/QC Note stating "Work Type
Dictated (WT Name) Not Found"
Scenario 6 - Work Type entered does not match information being dictated and is not in the work type
list
-Leave work type as populated and transcribe as dictated. Enter a QA/QC Note stating "Work Type
Dictated (WT Name) Not Found"
Scenario 1 - Dictator in the ADT screen matches the name of the person dictating the job
-Leave dictator as populated.
Scenario 2 - Dictator in the ADT screen (Named, Default Dictator or Generic ID) does not match the
name of the person dictating the job and name of person is found in database.
--Select name of person dictating from the database.
Scenario 3 - Dictator in the ADT screen (Named, Default Dictator or Generic ID) does not match the
name of the person dictating the job and name of person is not found in database.
1. Click on New at database search screen.
2. Spell the name phonetically.
Scenario 4 - Dictator in ADT screen is Default Dictator or Generic ID and the name of the dictator is not
stated.
1. Click on Name>New.
2. Populate the New contact as follows:
Last Name: UNKNOWN
First Name DICTATOR
Dictated For
The Dictated For field will appear when the dictator is required by the facility to have someone else sign
the report with or for the dictator.
Populate this field as dictated. If you do not populate the field, an alert will appear reminding you that
this field is not populated. If the dictator does not state whom he/she is dictating for, send the report
without the field populated.
Example: Resident physician dictating for their Attending physician - in this case, the resident would be
the dictator and their attending would be the dictated for. Dictator may state this as "This is Dr. Smith
dictating for Dr. Jones" or "This is Dr. Smith. Attending is Dr. Jones."
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MANDATORY ADT SECTION (top right section)
Mandatory ADT fields
Fields will populate with ADT or require manual entry based on dictated information.
Mandatory and Additional ADT fields will change based upon client facility/work type of the current job.
Note: A blank mandatory ADT field does not necessarily route a report to another
stage/person before being sent to the client.
Note: A blank additional ADT field will not route a report to another stage/person before
being sent to the client.
Tip: To enter current date in any date field, such as Admit Date, Discharge Date,
etc., use Ctrl+T. Use Ctrl+Y to enter yesterday’s date. Use + and - to increment and
decrement the date in the date field. This shortcut is based on the current date and
time on the DocQscribe user's computer NOT the dictated date and time.
ADT Matching
Scenario 1 - Patient demographic data populates automatically:
All ADT demographic information must be verified. Information dictated takes precedence over what
is populated.
Note: It is the responsibility of all DocQscribe users who access a job to ensure that the
ADT used on the job matches the patient and visit information from the dictator.
Incorrect ADT could cause multiple negative impacts to the report and ultimately
could affect patient care.
Example: One attending physician dictating for another - in this case, the attending dictating would
appear in the dictator field and the signing physician would be the dictated for. Dictator may state "This
is Dr. Williams dictating for Dr. Jones" or "This is Dr. Williams covering for Dr. Jones."
Date of Service
The Date of Service field is used to populate some of the following fields: Date of Procedure, Date of
Operation, Date Seen, Date of Consultation, Exam Date, Procedure Date, etc.
Field may be in mandatory or additional ADT window; must manually populate when dictated.
If not dictated or provided in the ADT, do not add.
Note: If you need to refer to the dictation date, the date/time dictated displays in Eastern
Time Zone in the ADT demographics window.
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Physician Fields
Referring Doctor, Attending Doctor, Assistant, PCP, etc.
Populate from database as dictated. Refer to the Available Names Database section.
Searching
When using search fields (last name, first name, specialty or access code), remember that you can and
should use the wild card of % if you only have partial information. Try single field searches, or narrow
down with partial multiple search fields. Need to think outside the box on possible spellings.
View Option
Allows the transcriptionist to view all available information that is not seen in the names window.
Note: If a fax number is dictated for a contact that is not located in the database, transcribe
the fax number in the Last name field after the last name that is dictated to ensure
that the fax number will appear on the final report for the client.
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Incomplete Dictation Instructions
INCOMPLETE OR CANCELED DICTATIONS
If you are transcribing a report and the dictation suddenly ends or is canceled by the dictator, you
should:
1. Verify you are at the end of the dictation by checking your audio slider. Enter two lines and
transcribe in all capital letters - DICTATION ENDS HERE.
2. Create a QA/QC Note stating DICTATION ENDS HERE. This process does not require the
report to be sent to QA manually.
NO DICTATION
MedQuist MTs are instructed to edit the work type entered by the dictator to a "no dictation" work type
when the audio associated with the voice file submitted by the dictator does not contain dictation which
could be transcribed. Examples include, but are not limited to, jobs with preamble information (dictator
identifying himself and/or other information) and then ending the dictation file without continuing with
the dictation; dictator enters the dictation job, may say a few words, but then records hold music, silence
or static; dictator begins the dictation, perhaps identifies the patient, but then states that she/he will
dictate later or this dictation has already been completed, etc.
ADDENDUM/CONTINUATION
If dictator states he/she is dictating an addendum/continuation to a previously dictated report, you
should:
1. Change work type Addendum work type if available. If the Addendum work type is not
available to choose in the work type list, leave the work type as entered by the dictator.
2. Type ADDENDUM or CONTINUATION at the top of your report in a red tagged heading.
3. Transcribe as dictated.
4. Create a QA/QC Note stating ADDENDUM or CONTINUATION.
5. Upload the job. This process does not require to be sent to QA manually.
</ADDENDUM/>
The patient will follow up with the Primary Care Physician……..
</PLAN/>
The patient will begin with physical therapy……..
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QA/MME Instructions
QA Marker Protocol
If a QA Marker cannot be resolved, leave the QA Marker in the text of the document.
Note: The QA Markers will match the voice files as long as they are inserted during
transcription before the voice file completes (beeps) at the end.
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Work Type Specific Instructions
Any unique information pertinent to a work type will be noted under the Work Type Instructions
Category.
OPTION 1 - Mandatory Letter Standard that includes only </ADDRESS/> and </BODY/>
tags.
Note: Do not remove any headings. Do not transcribe anything other than </ADDRESS/> above the
</BODY/> tag.
</BODY/>
Dear Dr. Doctor:
Sincerely,
Note: Do not remove any headings. Do not transcribe anything other than </ADDRESS/> above the
</BODY/> tag.
</BODY/>
Dear Dr. Doctor:
</CLOSING/>
Sincerely,
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Dictator Specific Instructions
Any unique information pertinent to a dictator will be noted under the Dictator Specific Instructions
Category.
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Physician Nomenclature
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Appendix
Demographics and ADT Screen Information
Dictation Job No
The Dictation Job Number is the identification assigned to the audio/dictation file. This is not a unique
identifier. It can be used by the dictator and the client for dictation documentation.
Split Jobs will use the same dictation job number as the master/originating job.
Date/Time Dictated
The Date/Time Dictated field populated with the date and time the report was dictated
Note: The Date/Time dictated will always appear in Eastern Time Zone.
Transcribed By
This field will populate with the DocQscribe user names of anyone who transcribes or edits the job. This
information will populate appropriately as changes are made and saved to the particular job in
DocQscribe.
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Function Reason
Explains why a report routed to QA. QA should look at this section on every job.
Could include one or more of the following:
- QA Marker(s) found in text
- QA Rule for Client Facility, DocQscribe User, Dictator or Work Type = 100% review
- Always added for this type of job = 100% review for ILP
- Added by DocQscribe User = User checked box to send to another stage
Search by name ending. Possibly “sky” or “ski” (try search using both spellings)
Search by partial last name. Narrow down by including all first names beginning with B.
Search by specialty. CAR will bring up all physicians with Cardiovascular, Cardiology, Cardiothoracic, etc
(whatever specialty name facility uses).
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