RMT CKT cheat sheet

Prefixes modify meaning without changing the part of speech: brady- = slow, tachy- = fast, hyper- = above normal, hypo- = below normal, dys- = difficult or painful.

Common suffixes by category: -itis = inflammation; -ectomy = surgical removal; -otomy = incision into; -ostomy = creating a stoma; -plasty = surgical repair; -scopy = visual examination.

Combining vowel (usually o) is inserted between a root and a suffix that begins with a consonant, and between two roots: cardi/o + my/o + pathy = cardiomyopathy.

A suffix beginning with a vowel replaces the combining vowel: hepat + itis = hepatitis, not hepat-o-itis.

Roots for body parts: cardi- heart, hepat- liver, nephr- kidney, gastr- stomach, enter- intestine, oste- bone, my- muscle, neur- nerve, pulmon- lung, dermat- skin.

Directional prefixes: ab- away from, ad- toward, ante- before, post- after, infra- below, supra- above, inter- between, intra- within, retro- behind, sub- under.

Number prefixes: mono-/uni- one, bi-/di- two, tri- three, quadri- four, poly-/multi- many, hemi-/semi- half.

Plural formation follows Greek and Latin patterns: -a (vertebrae), -ae (axillae), -i (bronchi), -ices (appendices), -es (diagnoses), -ta (ata).

Body planes: sagittal divides left and right; coronal (frontal) divides anterior and posterior; transverse divides superior and inferior.

Anatomical position: standing erect, face forward, arms at sides with palms forward, feet flat and directed forward.

Four abdominal quadrants: RUQ (liver, gallbladder), LUQ (stomach, spleen), RLQ (appendix, cecum), LLQ (descending colon); nine regions include epigastric, umbilical, and hypogastric.

Directional terms: anterior/ventral toward front, posterior/dorsal toward back, proximal nearer the trunk, distal farther from the trunk, medial toward midline, lateral away from midline, superficial near surface, deep internal.

Vital signs: adult resting heart rate 60–100 bpm, respiratory rate 12–20/min, blood pressure <120/80 mmHg (normal), oral temperature 36.5–37.5 °C (97.7–99.5 °F), SpO2 ≥95%.

Common disease processes: inflammation (rubor, calor, dolor, tumor, functio laesa), infection (pathogen invasion), neoplasm (uncontrolled cell growth), ischemia (reduced blood flow), necrosis (cell death), fibrosis (scarring).

Cardiac cycle: systole = ventricular contraction (ejection); diastole = ventricular relaxation (filling); normal resting stroke volume ~70 mL, cardiac output = heart rate × stroke volume.

Respiratory physiology: inspiration active (diaphragm contracts, volume increases, pressure drops); expiration passive at rest; gas exchange at alveoli via diffusion.

Common abbreviations: BP blood pressure, HR heart rate, RR respiratory rate, T temperature, WNL within normal limits, SOB shortness of breath, N/V nausea/vomiting, HPI history of present illness.

Routes of administration: PO by mouth, IV intravenous, IM intramuscular, SC subcutaneous, SL sublingual, PR per rectum, topical, inhaled; IV gives fastest systemic onset.

Common dosage abbreviations: q.d. once daily (avoid; write "daily"), b.i.d. twice daily, t.i.d. three times daily, q.i.d. four times daily, q4h every 4 hours, PRN as needed, stat immediately, NPO nothing by mouth.

Metric conversions: 1 g = 1000 mg; 1 mg = 1000 mcg; 1 L = 1000 mL; 1 tsp = 5 mL; 1 tbsp = 15 mL; 1 kg = 2.2 lb; 1 inch = 2.54 cm.

The "five rights" of medication administration: right patient, right drug, right dose, right route, right time (some add right documentation).

Common lab reference ranges (adult): hemoglobin 13.5–17.5 g/dL (male), 12.0–15.5 g/dL (female); hematocrit 41–53% (male), 36–46% (female); WBC 4,500–11,000/µL; platelets 150,000–450,000/µL.

Chemistry: sodium 135–145 mEq/L, potassium 3.5–5.0 mEq/L, chloride 98–106 mEq/L, glucose (fasting) 70–99 mg/dL, BUN 7–20 mg/dL, creatinine 0.6–1.2 mg/dL.

Coagulation: PT 11–13.5 sec, INR 0.8–1.1 (therapeutic on warfarin often 2–3), aPTT 25–35 sec; elevated INR raises bleeding risk.

Specimen collection: fasting lipid panel requires 9–12 h fast; blood cultures drawn before antibiotics; CBC in lavender (EDTA) tube; chemistry in gold/red (serum) tube.

Subject–verb agreement: singular subject takes singular verb; compound subjects joined by "and" take plural; "or/nor" agrees with nearest subject.

Comma rules: separate items in a series, set off nonrestrictive clauses, after introductory elements, before coordinating conjunction joining independent clauses; do not use comma to join two independent clauses (comma splice).

Semicolon joins closely related independent clauses or separates items in a series that already contain commas; colon introduces a list or explanation after a complete clause.

Apostrophe: singular possessive adds 's (patient's chart); plural possessive adds ' after s (patients' charts); do not use apostrophe for plural (BP's is incorrect unless possessive).

Hyphenate compound modifiers before a noun (well-known physician, 2-week follow-up); do not hyphenate after the noun (the physician is well known).

Numbers: spell out zero through nine in general prose; use numerals for 10 and above, for measurements, vital signs, lab values, and medication doses.

Active voice preferred in clinical documentation: "The nurse administered the medication" rather than "The medication was administered."

Avoid dangling modifiers: place the modifier next to the word it modifies ("After reviewing the chart, the physician ordered labs" not "After reviewing the chart, labs were ordered").

Parallel structure: items in a list or series should share grammatical form ("documenting, coding, and filing" not "documenting, coding, and to file").

SOAP note structure: Subjective (patient's report), Objective (exam findings, labs, vitals), Assessment (diagnosis or impression), Plan (treatment, tests, follow-up).

HPI elements (OLDCARTS): Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity.

Discharge summary components: admission and discharge dates, diagnoses, hospital course, procedures, medications at discharge, follow-up instructions, condition at discharge.

Operative report sections: preoperative diagnosis, postoperative diagnosis, procedure performed, surgeon and assistants, anesthesia, findings, technique, estimated blood loss, specimens, complications.

Progress note includes date/time, patient identifiers, subjective/objective status, assessment, plan, and signature with credentials.

Consultation report: reason for consult, history, exam, impression, recommendations, signature.

History and physical (H&P) sections: chief complaint, HPI, past medical/surgical/family/social history, review of systems, physical exam, impression, plan.

Documentation timeliness: entries dated and timed; late entries labeled "late entry" with date/time of entry; no backdating; corrections by single line, initial, date, and reason.

Transcribe verbatim only when required (e.g., legal or psychiatric); otherwise edit for clarity while preserving meaning and never change clinical facts.

Flag inaudible or unclear dictation with a blank or [inaudible] placeholder rather than guessing; never invent numbers, drug names, or laterality.

Verify sound-alike terms: ileum/ilium, hypokalemia/hyperkalemia, hypertension/hypotension, abduction/adduction, dysphagia/dysphasia, pruritus/pruritis.

Confirm drug names against a reference list; look-alike/sound-alike pairs include Lasix/Losec, Celexa/Zoloft, hydralazine/hydroxyzine, oxycodone/hydrocodone.

Numbers and units: transcribe "5 mg" not "5mg"; use leading zero for doses less than 1 (0.5 mg), never trailing zero (5.0 mg).

Expand dangerous abbreviations: q.d. → daily, U → unit, IU → international unit, MS → morphine sulfate (spell out), µg → mcg.

Dictation quality checks: playback speed control, foot pedal, headset; maintain a personal word list of provider-specific terms and preferred spellings.

Proofread against the audio at least once; verify patient name, date of birth, and medical record number match the header.

HIPAA Privacy Rule protects individually identifiable health information (PHI); permitted uses include treatment, payment, and operations (TPO) without authorization.

Minimum necessary standard: disclose only the least amount of PHI needed for the purpose.

HIPAA Security Rule covers electronic PHI (ePHI): administrative, physical, and technical safeguards; breach notification generally within 60 days of discovery.

Patient rights under HIPAA: access to records, amendment, accounting of disclosures, restriction requests, confidential communications, and complaint without retaliation.

Release of information requires a valid authorization: patient signature, date, purpose, specific information, expiration, right to revoke, and statement about redisclosure.

Special protections often apply to substance use disorder records (42 CFR Part 2), HIV/AIDS, mental health, and genetic information; stricter consent rules may apply.

Ethical principles: autonomy (patient choice), beneficence (do good), nonmaleficence (do no harm), justice (fairness), confidentiality, veracity.

Scope of practice: transcriptionists and coders do not provide clinical advice; refer clinical questions to the provider; follow employer policies and state law where stricter than federal.