Transcription Services Formatting Standards - Consultations and Letters of Correspondence
|Policy:||Transcription Services Formatting Standards - Consultations and Letters of Correspondence|
|Policy Nr:||Sec 10 - 04|
|Target Review Date:||2017-12-31|
|Main Stakeholder:||Transcription Manager|
This policy defines standard formatting as part of Transcription Services.
The Department of Internal Medicine is committed to ensuring that a professional appearance is maintained for all correspondence. A consultant report is dictated by the consultant and is addressed to the referring physician.
A consultation letter can be dictated in either a letter or report format and should contain the:
- date of consultation
- reason for the consultation
- physical and laboratory evaluation of the patient
- consultant’s impression of the patient’s condition, and
- consultant’s recommendation
There should also be a complimentary close at the end of each letter.
Letters of correspondence include letters reporting laboratory values, letters of referral, letters of second opinion or any other correspondence as may be required.
Only department-approved letterhead will be used. Macros will be created for each section in the upper right hand corner of the page including the section telephone and fax number.
Only Times New Roman – size 12 will be used.
Full block style will be used on all correspondence. With the full block style all components of the letter such as date, inside address, salutation, body and close are justified (all text is aligned to the right, left or both margins). Full-justified style will be used (all text is placed equally between margins, with text aligned to both the left and right margins), without tabs at the beginning of paragraphs.
Margins will be one inch each from the left, right and bottom margins with one-half inch from any letterhead information. The body of the letter will be single-spaced. All other spacing will be:
- A minimum of three blank lines (quadruple spacing) between the date and the inside address. The date of the clinic visits will be used as the date of the letter.
- The inside address will have the name of the physician on one line. The second line will have the civic address, with the third line indicating the city, province and postal code. The two letter provincial abbreviations will be used (eg. MB, AB, ON).
- A maximum of one line (double spacing) will be used between the last reference line and the salutation.
- The patient demographics will be in bold print and will include the Date of Birth, Hospital Chart Number, Healthcare (MHSC) number and PHIN number.
- Single spacing will be used throughout the body of the text of the letter.
- Double spacing will be used between the page two information at the top of page two, and the continuation of the body of text.
- Double spacing will be used between the last line of the body of text and the complimentary close. In the event that the complimentary close and the signature block stand alone on the second page, a page break in a position that provides at least two lines of text preceding the complimentary close on the page containing the complimentary close and signature block will be used.
- Two blank lines (triple spacing) will be used between the complimentary close and the signature block.
- Double spacing will be used between the signature line and the sign-off initials and any copy notations.
All letters will show the date dictated and the date transcribed.