The Medical Record Abbreviation
You are transcribing a telephonic deposition of an orthopedic surgeon in a workers' compensation matter. The surgeon testifies about the plaintiff's lumbar spine. During testimony, the surgeon says: "The MRI showed an L4-L5 disc herniation with moderate central canal stenosis, and I prescribed 5 mg oxycodone q.i.d. for breakthrough pain." Later, the surgeon says: "The patient had a history of C-section and also reported occasional PVCs." You must produce a certified transcript. The attorney asks you to "clean up the medical jargon so the jury can understand it." You also notice the surgeon says "L4-L5" once and "L5-S1" later when describing the same imaging study.
1. Should you expand or simplify the surgeon's medical abbreviations in the certified transcript? Explain your reasoning.
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No. The certified transcript should record the surgeon's testimony as spoken, including abbreviations such as L4-L5, q.i.d., and PVCs. Expanding or simplifying jargon would alter the witness's actual words and could change meaning-for example, q.i.d. means four times daily, and paraphrasing could introduce error. The jury's understanding is a matter for the parties, who may ask the witness to explain terms on the record or present an interpreter or glossary. The reporter's duty is verbatim accuracy, not editorial translation. If a term is unclear on the audio, the reporter should use an inaudible notation rather than guess. The reasoning is that the transcript is evidence, and the reporter must not become an advocate or editor. Accuracy and neutrality control.
2. The surgeon says "L4-L5" and later "L5-S1" for the same study. How should the reporter handle this apparent inconsistency?
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The reporter should transcribe each statement exactly as spoken, at the point it occurred, without correcting either reference. The apparent inconsistency is a matter for the parties to explore through cross-examination or clarification; it is not the reporter's role to reconcile it. If the audio is clear, the words stand as spoken. If the audio is ambiguous-for example, if the speaker mumbled-the reporter may use an inaudible notation or, where appropriate, verify against the audio backup, but must not substitute a medically plausible level. The reasoning is that altering testimony to make it consistent would destroy the record's integrity and could constitute misconduct. The reporter preserves the conflict; counsel resolves it.
3. The attorney asks you to "clean up the medical jargon." What is the appropriate response and professional basis?
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The appropriate response is to decline to alter the testimony in the certified transcript and to explain that the reporter records verbatim. The reporter may offer practical alternatives: the attorney can ask the witness to explain the terms on the record, or the parties can arrange for a glossary or expert explanation. The reporter should remain courteous and professional, not confrontational. The professional basis is the duty of accuracy and impartiality: the reporter is not an editor, translator, or advocate. Changing jargon could misstate the physician's testimony and expose the reporter to challenge. If the attorney persists, the reporter should document the request and consult applicable rules or a supervising official. Accuracy and neutrality govern.