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I am having trouble trying to figure out when, and when no to make a list, or heading.
First, I know the headings, in the beginning, are ALL CAPS, like FAMILY HISTORY, MOTOR, REFLEXES, but then, the Neurologist begins listing (on the independent medical evaluation, under "Record Summary/Provider") tons and tons of dates like:
9/17/2010 PT. Dr. So and So. Same template.
Chiropractic Assessment: Palpation L2, L3, L5, L5 and S1, taut and tender MS fibers and fixation. x-rays: AP and lateral cervical and lumbar spine, decreased cervical lordosis and right list, lumbar list left with pelvic unleveling.
Diagnoses: Lumbago, lumbosacral subluxation, cervical subluxation, cervicalgia.
Checks: Neck pain, low back pain, ache, pinching, pulling, Associated with Checks: Balance problems.
Many of these Diagnoses, examination, assessment etc lists will be repeated for dozens and dozens of more dates. Should chiropractic assessment be bolded every time, or just the first letter capitalized? How do I know when to make a list, or just put a colon and use commas to separate them? etc. I don'the have an ADHI reference book, and want to do it the correct way. Can someone help me please?