Welcome to Nuance Transcription Services English Grammar and Punctuation

Training! The purpose of this training session is to provide an overview of the English
grammar and punctuation essentials that a medical language specialist needs to
possess in order to properly transcribe medical reports.

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As noted, the purpose of this module is to provide an overview of English grammar
and punctuation as it pertains to a medical language specialist.

• Most often an MLS will transcribe verbatim. Verbatim means typing word for word,
an exact reproduction, using exactly the same words, and no variation compared
to what was dictated.
• Occasionally the MLS will be required to make an edit. Some edits are based on
formatting guidelines, such as account specifics instructions and the Nuance
Transcription Guidelines, while other edits are grammatical edits.
• Knowing our parts of speech along with grammar and punctuation rules makes our
work much easier when deciding when a grammatical edit is required.

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Until we know how words function in the specific sentence, we will only be guessing
the grammar and punctuation. Guessing the punctuation has the potential to change
the meaning of the sentence from what the dictator intended.

Subject - tells who or what the sentence is about. The subject of a sentence is the
person, place, thing, or idea that is doing or being something.
Verb - Verbs are the “doing” words. A verb can express a physical action, a mental
action, or a state of being.

To find the subject and verb, always find the verb first. Then ask who or what
performed the verb.

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Often the subject will come before the verb, such as in this sentence.

The jet engine passed inspection.

“Passed” is the verb. Who or what passed? The engine, so “engine” is the subject.

Sometimes the subject will come after the verb, such as in this sentence.

From the ceiling hung the chandelier.

The verb is “hung.” Who or what is hung? The chandelier (NOT the ceiling.)

Always find the verb first. Then ask who or what performed that verb, and you will be
able to find the subject. This will be necessary for proper subject-verb agreement in
any sentence.

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A pronoun is a word that is used in the place of a noun in a sentence. On this slide is
a list of the most common pronouns.

Sometimes the pronoun replaces a noun and serves as the subject of a sentence,
such as in this example:

He refused to sign the form.

The verb is “refused.” Who refused? “He” did. The subject is the pronoun “he.”

Sometimes the pronoun replaces a noun and serves as a possessive adjective, such as
in this example:
Her cologne perfumed the office.
The verb is “perfumed.” What perfumed? Cologne. The subject is
cologne. Who’s cologne was it? It was “her” cologne. Her is the pronoun and it
functions as a possessive adjective, explaining to whom the cologne
belonged.

Sometimes there are multiple pronouns serving multiple functions, such as in this
sentence:
Next we focused our attention on the axilla.
There are two pronouns in this sentence. The verb of the sentence is “focused.” Who
focused? “We” did. The subject of the sentence is the pronoun “we.” What did they

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focus? Attention. Who’s attention? “Our” attention. The pronoun “our” is a
possessive adjective.

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The most simple of sentences contains a subject and a predicate.

A subject means a “noun” or pronoun which will denote a person, place, or thing.
A predicate means “verb” which will denote an action.

A simple subject tells who or what the sentence is about.

A simple verb tells the activity of the subject.

Here are some examples of simple sentences.

S P
He bled.
Flowers bloomed.
Hemostasis achieved.

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A sentence may have more than 1 subject. Here is an example:
The doctor and nurse rushed to the OR.
The verb is rushed. Who rushed? Both the doctor and the nurse. The subjects in that
sentence are “doctor” and “nurse.”

A sentence may have more than 1 predicate.

We ran, swam, and bicycled.
The predicates (or verbs) in that sentence are “ran,” “swam” and “bicycled.” Who ran,
swam, and bicycled? “We” did. The subject of the sentence is the pronoun “we.”

A sentence may have more than 1 subject & more than 1 predicate.
The legs and ankles revealed petechiae and were swollen.
The verbs in the sentence are “revealed” and “were.” What revealed petechiae and
were swollen? The legs and ankles. The subjects of the sentence are “legs” and
“ankles.”

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At the heart of the predicate is a verb. In a simple sentence, such as “hemostasis
achieved,” the predicate consists of a single verb: “achieved.”

In addition to the verb, a predicate can contain direct objects, indirect objects, and
various kinds of phrases, such as in the next sample sentence.

The women in our office are experienced instructors.

The verb is “are,” and “experienced instructors” tells more information about that
verb (explains what the women “are”). The entire phrase “are experienced
instructors” functions as the predicate.

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Subjects and verbs must agree in number.
A singular subject requires a singular verb.
A plural subject requires a plural verb.

Let’s go through some sentences to see the difference between singular and plural
verbs.

SENTENCE VERB TYPE

Abdomen (was, were) flat. Singular
(The subject “abdomen” is singular. Only one abdomen is being discussed. The
singular verb “was” is required to match the singular subject.)

Following explanations, he (agree, agrees) to proceed. Singular

(The subject “he” is singular. Only one person is agreeing to proceed. The singular
verb “agrees” is required to match the singular subject.)

Ecchymoses (were, was) present. Plural

(The subject “ecchymoses” is plural. The plural verb “were” is required to match the
plural subject.)

The nurses (note, notes) hypertension. Plural

(The subject “nurses” is plural. Several nurses noted the hypertension. The plural

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verb “note” is required to match the plural subject.)

Eyes (was, were) conjugate. Plural

(The subject “eyes” is plural. Both eyes were examined. The plural verb “were” is
required to match the plural subject.)

Our aides (are, is) demanding more pay per hour. Plural
(The subject “aides” is plural. Multiple aides are demanding more pay. The plural verb
“are” is required to match the plural subject.)

The dorsum (was, were) incised. Singular

(The subject “dorsum” is singular. Only one particular dorsum is being incised. The
singular verb “was” is required to match the singular subject.)

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It is important to note the distinction between plural nouns and plural verbs.

In the English language, plural nouns end with the letter “s” or “es,” depending upon
how the word is spelled. For example, “ligament” is singular while “ligaments”
(ending with the letter “s”) is plural.
However, with verbs, the opposite is true. Normally when a verb ends with the letter
“s,” it denotes a singular verb. A plural verb does not end in the letter “s.”

Let’s use one of sample sentences as an example.

The nurses note hypertension.
The noun, “nurses,” is plural. It ends with the letter “s” and more than one nurse is
being referred to.
The verb, “note,” does NOT end with an “s.” The nurses…note. “Note” is a plural
verb.

If the sentence was worded talking about only one nurse, then the sentence would
be
The nurse notes hypertension.
The noun, “nurse,” is singular. It does NOT end with the letter “s.” Only one particular
nurse is being referred to.
The verb, “notes,” is singular. It ends with the letter “s.” The nurse notes… “Notes” is
a singular verb.

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In terms of transcription, verb tenses are almost always transcribed verbatim. The
oversimplified definition is that there are 3 tenses.

past present future

I had I have I will have
I drank I drink I will drink
You wrote You write You will write

We have no directive to maintain same tenses throughout a report or even a

paragraph or even within a sentence. Doctors are like us--they mix tenses
indiscriminately. No clarity is sacrificed when they do. Only edit for things like
subject-verb agreement or when a particular tense is demanded in order for a
sentence to make sense.

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“Time-sensitive” refers to “past,” “present,” or “future” verbs. Rarely must you edit a
verb tense for a dictator. Change the tense only when a verb is “time-sensitive,”
which is going to be extremely obvious. Here is an example:

Dictated: She will come to the office yesterday for her appointment.
There is an obvious error in that sentence. Yesterday means it already happened, so
one would expect the verb to be past tense. However, the verb is “will come,” which
is future tense. Either the dictator confused the verb or mixed up the words
“yesterday” and “tomorrow.”

The dictator either meant:

She came to the office yesterday for her appointment. (Past tense. The
appointment already happened.)
Or
She will come to the office tomorrow for her appointment. (Future tense. The
appointment has not happened yet. It will occur in the future.)

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Now that we have discussed the basic building blocks of a sentence—subjects and
predicates, we can use that knowledge to decide how to punctuate a sentence.

Complete sentences are also called “independent phrases,” and complete sentences
have a both a subject (usually a noun) and a predicate (or verb).
Incomplete sentences are also called “sentence fragments” or “clipped sentences,”
and incomplete sentences are missing either the subject or the predicate.
To determine whether a sentence is complete or incomplete, look for subjects and
predicates (verbs).

Let’s look at he following sentences to determine if each is a complete sentence or an

incomplete sentence. If it is incomplete, we will decide what is missing from the
sentence.

SENTENCE COMPLETE? WHAT’S

MISSING?
Past history is insignificant. Complete ----
(Nothing is missing from the sentence. The subjective is “history” and the verb is
“is.”)

Had a past history of phlebitis. Incomplete

Subject
(The verb is “had.” The subject is missing. It is unclear WHO had a past history of
phlebitis.)

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She is a pharmaceutical representative. Complete ----
(Nothing is missing from the sentence. The subject is “she” and the verb is “is.”)

Follow up in 2 weeks. Incomplete Subject

(The verb is “follow up.” The subject is missing as it is unclear WHO must follow up in
2 weeks.)

Nose clear. Incomplete

Predicate
(The subject is “nose.” The verb “is” is missing.)

She has 2 brothers and 1 sister. Complete ----

(Nothing is missing from the sentence. The subject is “she” and the verb is “has.”)

Dictators often use clipped sentences, especially in the physical examination portion
of a report. “Nose is clear” is a complete sentence. “Nose clear” is an incomplete, or
clipped, sentence. The verb has been clipped out. On the job, always transcribe
verbatim in terms of complete versus incomplete sentences.

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A conjunction is a part of speech that connects words, sentences, phrases, or clauses.
The most common conjunctions may be recalled by remembering the acronym
FANBOYS.
For
And
Nor
But
Or
Yet
So
To use a comma or not before a conjunction completely depends upon how it used in
the sentence.

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“Compound” means “more than one” or “plural.” Compound parts of speech are
connected by a conjunction.

A conjunction may link compound subjects.

The doctor and nurse rushed to the OR.
There are 2 subjects: “doctor” and “nurse.” The 2 subjects are linked by the
conjunction “and.” There is no comma used before the word “and” when linking
compound subjects.

A conjunction may link compound predicates/verbs.

We ran and swam and bicycled.
There is no comma used before the word “and” when the conjunction appears before
each of the compound predicates.

We ran, swam, and bicycled.

In this sentence there are 3 or more predicates (or verbs): “ran,” “swam,” and
“bicycled.” However, the conjunction “and” is only used before the last predicate.
There must be a comma between “ran” and “swam” since they are 2 separate
actions. The comma is required to replace the missing word “and.” Note that the
comma before the conjunction “and” is optional.

A conjunction may link 2 or more complete or incomplete sentences. Here is an

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example:
Her mother signed the admission papers, and she was
admitted to the ER.
In this case, there is a comma placed before the conjunction “and” since it is being
used to connect 2 complete clauses. This is a compound sentence, which is our next
topic.

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To properly punctuate a sentence, one must differentiate between a compound
sentence, which contains 2 or more independent clauses, versus a dependent phrase.

Remember the definitions from earlier:

• Complete sentences (also called independent clauses) have a subject and a
verb/predicate. These are “independent” because the thought expressed can
stand on its own. The sentence makes perfect sense since everything required is
present. The subject is present, so we know who is being discussed, and the verb
is present, so we know what the subject is doing.
• Incomplete sentences (also called “sentence fragments” or “clipped sentences”)
are missing the subject or the predicate. They are “dependent” because the
thought expressed cannot stand on its own. Part of the sentence (whatever is
missing/clipped out) is dependent upon words elsewhere in the sentence in order
to make sense.
• To determine whether a sentence is complete or incomplete, look for subject(s)
and verb(s).

A compound sentence means that both phrases before AND after the conjunction
that ties them together are complete and can stand alone on their own.

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Let’s look at the difference between compound sentences that contain independent
phrases versus compound sentences that contain a dependent phrase.
Here’s our sample sentence:
I went to the store on Monday, and I bought some office supplies.

^ This is a compound sentence. A comma is placed before the conjunction (which is

the word “and”) since each part can stand on its own and expresses a complete
thought.

I went to the store on Monday.

^ That’s an independent phrase and can stand on its own.

I bought some office supplies.

^ That’s an independent phrase and can stand on its own.

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Now let’s take that same sentence but change the wording slightly so that now the
second half of the sentence contains a dependent clause.
I went to the store on Monday and bought some office supplies.
^ In this case, both parts of the sentence share the same subject (which is “I”). The
second phrase CANNOT stand on its own.

I went to the store on Monday.

^ That’s an independent phrase and can stand on its own. It expresses a complete
thought. We know who the subject is (I) and what that subject was doing (went to
the store).

Bought some office supplies.

^ This is not complete. The subject is “missing” (because the subject, which is “I,” is
present only in the first half of the sentence.) It cannot stand on its own and does
not express a complete thought. The reader has no idea who bought some office
supplies. This part of the sentence must be connected to the first part of the
sentence in order to make sense. You cannot separate a dependent phrase with a
comma.

Thus, use a comma when a conjunction is used to connect two or more independent
phrases. Do not use a comma when a conjunction is used to connect a dependent
phrase.

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Let’s look at a few more examples of compound (complete) sentences versus
sentences that contain dependent clauses.

Remember, “compound” means “more than one.” A compound sentence contains

more than one independent clause. Each part of the sentence before and after the
conjunction contains a subject, a verb, and expresses a complete thought.
A dependent sentence means that at least one part of the sentence contains an
incomplete clause. Either the subject is missing or the verb is missing. That
incomplete clause is dependent upon another phrase in the sentence for the reader
to understand either the subject or the verb and make sense.

The patient was discharged, and she was instructed to follow up in the office in 2
weeks’ time.
• The patient was discharged.
• She was instructed to follow up in the office in 2 weeks’ time.
^ This is a compound sentence. A comma is placed before the conjunction “and”
since each clause before and after the conjunction can stand on its own and
expresses a complete thought. In other words, you could remove the conjunction
“and” and instead have two separate sentences, and each of those sentences express
a complete thought.

Now let’s change the wording of the sentence slightly.

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The patient was discharged and was instructed to follow up in the office in 2 weeks’
time.
• The patient was discharged.
^ This part of the sentence is an independent clause. If we plucked this out and made
it its own sentence, the sentence would be complete since it expresses a complete
thought.
• Was instructed to follow up in the office in 2 weeks’ time
^ This part of the sentence (which is in red font on the slide) is a dependent clause.
The subject is missing. You could not pluck this out and make it its own sentence
since the reader would have no idea who was instructed to follow up in the office. It
is dependent upon the first half of the sentence in order for the reader to understand
the subject of the sentence, which is “patient.”

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Here is a short quiz about compound sentences versus dependent sentences.
Punctuate the following 6 sentences.

Remember, do not use a comma before a conjunction when the conjunction is used
to connect multiple subjects or multiple verbs.
What you are looking for are conjunctions that connect two independent phrases.
Look for subjects and verbs.
Do not click on the “next” button until you have jotted down which sentences should
have a comma and where that comma should go.

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Here are the answers to the quiz. Sentences 1, 2, and 6 are compound sentences and
require a comma before the conjunction. The required comma is highlighted in yellow
on the slide. In those three sentences, you could remove the conjunction “and”
(which appears directly after the yellow highlighted comma) and make each phrase
before and after that conjunction into their own sentences, and they would make
sense. Sentences 3, 4, and 5 are dependent, so no comma is used before the
conjunction. With sentences 3, 4, and 5, the first half of each sentence could stand
alone as its own sentence, but the second half of the sentence is incomplete and
does not express a complete thought. In each case, the subject is missing from the
second half of the sentence.

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Let’s look at each sentence in more detail. Remember we are looking for subjects
and verbs on either side of the conjunction (which will indicate if we are dealing with
complete clauses or incomplete clauses).

Sentences 1 and 2 are both complete. Each clause before and after the conjunction is
independent. Each contains a subject and a verb and expresses a complete thought.

1. The patient presented with a severe migraine, and she asked for an injection of
Imitrex.
• The patient presented with a severe migraine
• She asked for an injection of Imitrex

2. The patient has had nausea and vomiting and diarrhea and chills, and she said
she recorded a temperature of 102 degrees.
• The patient has had nausea and vomiting and diarrhea and chills
• She said she recorded a temperature of 102 degrees

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Now let’s look at sentences 3 and 4. Notice how the second half of sentences 3 and 4
are incomplete. They are each missing the subject.

3. They accept these risks and agree to proceed.

Sentence 3 contains a dependent clause in the second half. Only the first half
contains a subject and a verb and expresses a complete thought. The second half of
the sentence has the subject clipped out.
They accept these risks < Yes, that is complete and could stand on its own.
Agree to proceed
^ The reader has no idea who agreed to proceed. This clause is dependent upon the
first half of the sentence to understand the subject (“they”).

4. She had a low-grade fever at times during her hospital stay but after a few days
began to regain some strength.
Sentence 4 contains a complete clause in the first half. The second half of the
sentence has the subject clipped out.
She had a low-grade fever at times during her hospital stay.
^ Yes, that is complete and could stand on its own.
After a few days began to regain some strength
^ This phrase could not stand on its own. The reader has no idea who began to regain
strength. This clause is dependent upon the first half of the sentence to understand

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the subject (“she”).

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Lastly, let’s look at sentences 5 and 6. Remember, we are looking for subjects and
verbs on both sides of the connecting conjunction.

5. The patient was admitted to the medical floor where he was hydrated with IV
fluids and also cultured and started on IV antibiotic treatment.
The patient was admitted to the medical floor where he was hydrated with IV fluids,
< Yes, this could stand on its own and make sense.
also cultured and started on IV antibiotic treatment
^ The second half could not stand on its own. In sentence 5 only the first half of the
sentence contains the subject. The second half is dependent upon the first half to
understand who the subject of the sentence is (“patient”).

6. The incision was closed with 3-0 Prolene in interrupted fashion, and Steri-Strips
were applied to the skin.
The incision was closed with 3-0 Prolene in interrupted fashion
Steri-Strips were applied to the skin
Each clause before and after the conjunction is independent. Each contains a subject
and a verb and expresses a complete thought.

Remember, when deciding whether a comma is required before a conjunction, look

for subjects and verbs on either side of the connecting conjunction.

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An introductory phrase is like a clause, but it doesn't have its own subject and verb; it
relies on the subject and verb in the main clause. As the name implies, an
introductory phrase “introduces” a main clause.

Use a comma to separate an introductory phrase from the main independent clause
of the sentence.

Prior to reporting to the radiology suite, the patient had to submit their insurance
paperwork to the receptionist.

The main clause of this sentence is in blue on this slide: the patient had to submit
their insurance paperwork to the receptionist.
The introductory phrase is in purple: Prior to reporting to the radiology suite.

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Use a comma only when the introductory phrase comes before the main clause of
the sentence (when it is “introducing” the main clause).

Prior to reporting to the radiology suite, the patient had to submit their insurance
paperwork to the receptionist.

But if the word order is reversed, no comma is required:

The patient had to submit their insurance paperwork to the receptionist prior to
reporting to the radiology suite.
When the phrase comes AFTER the main clause, it is not introducing anything.

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Here is another example.
Introductory phrase:
During her last round of chemotherapy treatment, the patient experienced severe
nausea and vomiting.

An introductory phrase is considered to be an unusual word order. When the same

phrase comes at the end of the sentence, no comma is required.
The patient experienced severe nausea and vomiting during her last round of
chemotherapy treatment.

A phrase can only be introductory when it introduces the main clause of the
sentence. When it comes at the end of the sentence, it cannot be introducing
anything since nothing follows.

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An introductory phrase may occur at the very beginning of the sentence, or it may
introduce the main clause in the second half of a compound sentence.

The patient tolerated her treatment today without incident, but during her last
round of chemotherapy treatment, the patient experienced severe nausea and
vomiting.

The introductory phrase in this sentence, which is in purple font on the slide,
introduces the main clause of the second half of this compound sentence.

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An interrupting phrase quite literally interrupts the flow of the sentence. Place a
comma before and after an interrupting phrase. On this slide, the interrupting
phrases are in orange font.

• The appendectomy, which was performed by Dr. Mehta, is dictated under a

separate operative report.
• The lower extremities have diffuse weakness, greater on the right than the left,
with numbness and tingling.
• The patient, age 38, has no past history of bleeding or clotting disorders.

All of these sentences would still make sense and express a complete thought if the
interrupting phrase were to be removed.

• The appendectomy is dictated under a separate operative report.

• The lower extremities have diffuse weakness with numbness and tingling.
• The patient has no past history of bleeding or clotting disorders.

Since in each sample sentence the interrupting phrase interrupts the flow of the
sentence, place a comma both before and after the interrupting phrase.

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An interrupting phrase interrupts the flow of the sentence, but that information is not
critical for the meaning of the sentence.

• She states that she has migraine headaches, particularly upon awakening,
approximately 2 to 3 times per week.
• She states that she has migraine headaches approximately 2 to 3 times per week.

^ The sentence still makes sense without the interrupting phrase.

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• An appositive contains a noun or pronoun — often with modifiers — set beside
another noun or pronoun to explain or identify it.
• An appositive phrase is a specific type of nonessential phrase. It conveys “nice to
know” information, but that information is usually not necessary to complete the
meaning of the sentence.
• Appositive phrases may be at the beginning, middle, or end of a sentence.

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Here is an example of an appositive phrase.
Dr. Hoffman, a private-practice physician for the past 10 years, will be joining our
department on Monday.

The phrase “a private-practice physician for the past 10 years” is a phrase that
describes the subject (“Dr. Hoffman”). It is a nonessential phrase. The main meaning
of the sentence makes sense without the appositive phrase: “Dr. Hoffman will be
joining our department on Monday.”

An appositive phrase is a particular type of interrupting phrase. Because it interrupts

the flow of the sentence, and because the main meaning of the sentence remains
intact without the appositive phrase present, you must place a comma before and
after the appositive phrase.

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An appositive phrase may be at the beginning, middle, or end of a sentence. We can
use our sample sentence and reword it to show the appositive phrase at various
positions in the sentence.

Here is the sentence with the appositive at the beginning of the sentence:
A private-practice physician for the past 10 years, Dr. Hoffman will be joining our
department on Monday.
When an appositive phrase occurs at the beginning of a sentence, it acts like an
introductory phrase, and you must place a comma after the appositive phrase before
moving on to the main clause of the sentence.

Here the appositive phrase is in the middle of the sentence:

Dr. Hoffman, a private-practice physician for the past 10 years, will be joining our
department on Monday.
When an appositive phrase occurs in the middle of a sentence, it acts like an
interrupting phrase, and you must place a comma before and a comma after the
appositive phrase.

Lastly, here is the appositive phrase at the end of the sentence.

Joining our department on Monday will be Dr. Hoffman, a private-practice physician
for the past 10 years.
When an appositive phrase occurs at the end of a sentence, place a comma before

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the appositive phrase.

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Now we will discuss a part of speech called a direct object. Some people get
confused and think any noun in a sentence is the subject. A noun or pronoun may
also function as a direct object. A direct object is a noun or pronoun that receives the
action of a verb in a sentence. It answers the questions what? or whom? about the
verb.

Let’s take the following sentence: The car hit the tree.

The verb in the sentence is “hit.” What hit? The car. The subject is “car.” What did
the car hit? The tree. The word “tree” is the direct object.

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Direct objects may be a pronoun, but most often, direct objects tend to be nouns =
person(s), place(s) or thing(s). Let’s look at the following example:
The nurse noted her pulse, temperature, and respiratory rate.
The verb is “noted.” Who noted? The nurse. The subject of the sentence is “nurse.”
What was noted? The “pulse, temperature, and respiratory rate.” There are 3 direct
objects in this sentence.

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Sometimes a noun or pronoun in a sentence functions as the object of a preposition.

A preposition is a function word that combines with a noun or pronoun to make a

phrase which, altogether, relates to the rest of the sentence. Prepositions are always
combined with other words in structures called prepositional phrases. Prepositions
on their own convey nothing. Prepositions must be combined as part of a
prepositional phrase in order to make sense.

He bled (through the bandage.)

The preposition is “through.” The phrase “through the bandage” is the prepositional
phrase. The noun “bandage” is the object of the preposition.

The subject of the sentence is “he” and the verb is “bled.” The prepositional phrase
“through the bandage” provides additional detail about where the patient bled. On
its own, the preposition “through” conveys nothing. It must be part of a
prepositional phrase (through the bandage) in order to make sense.

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There are many prepositions in the English language. Shown here is a list of some of
the most common prepositions.

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Here are the punctuation rules for prepositional phrases.
• Very seldom do you place a comma before, in the middle of, or after a
prepositional phrase. (There are exceptions.)
• Prepositional phrases are almost always essential, providing further information
about the word they modify.
• Frequently there will be several back-to-back prepositional phrases.

Here is an example of back-to-back prepositional phrases.

The patient presented complaining (of pain) (in the right wrist and right hip) (after
falling) (on an icy driveway.)

There are 4 prepositional phrases in that sentence. The second version of the
sentence on this slide displays a different color for each of the 4 prepositional
phrases.

38
Be very careful of prepositional phrases and don’t let them throw you off as they
often come between a subject and verb.
MTs often mistakenly match the verb of the sentence to the object of the preposition
instead of to the subject of the sentence.
As we have discussed, always identify the verb in the sentence first. Next identify the
subject of the sentence. Then match subject and the verb. Prepositional phrases
have no bearing on subject-verb agreement, so ignore any prepositional phrases that
come in between a subject and its verb when deciding proper subject-verb
agreement.

Let’s look at the following sentence as an example.

Each of the test results was contradictory.

Again, you must “ignore” the prepositional phrase (of the test results) and match the
subject with the verb: each was contradictory.
Many MTs get tripped up by prepositional phrases and match the object of the
preposition in the prepositional phrase (“results”) with the verb of the sentence, and
that is not correct.
Always match the subject with the verb. Don’t get tripped up by prepositional
phrases.

39
Sometimes a word serves a different function in one sentence versus another. Let’s
use some of parts of speech we have already discussed to illustrate this concept.
A preposition begins prepositional phrase.
A conjunction is a linking word.

In the first group of sentences, the word “for” is used as a different part of speech in
each.
• I opened the door for my mother. (Here “for” is a preposition, and the
prepositional phrase is “for my mother.” )
• I opened the door, for I saw that she could not open it. (Here the word “for” is a
conjunction, linking 2 independent clauses together.)

In the second group of sentences, the word “since” is used as a different part of
speech in each.
• The patient has received no further x-rays since yesterday. (Here the word “since”
is a preposition, and the prepositional phrase is “since yesterday.”)
• The patient has received no further x-rays, since the radiology department was
closed for the holiday weekend. (Here the word “since” is a conjunction, linking 2
independent clauses together.)

40
Use a comma between adjectives and nouns in a series.

Note that when the last item in the series is preceded by a conjunction, a comma
before the conjunction is optional. Note that the comma in brackets and gray font on
this slide is where an optional comma may be placed.
The patient denies any nausea, vomiting, diarrhea[,] or chills.
The comma is mandatory after the words “nausea” and “vomiting” as they are
distinctly separate items. A comma is optional before the final item in the series
(which is “chills”) since a conjunction comes just before it.

The patient said she has a toothache, eye pressure, nasal congestion, and ringing in
her ears.
The comma is mandatory after the words “toothache, and “eye pressure” as they are
distinctly separate items. A comma is optional before the final item in the series
(which is “ringing in her ears”) since a conjunction comes just before it.

Let’s reword our sample sentences slightly and connect each item in the series with a
conjunction.
The patient denies any nausea or vomiting or diarrhea or chills.

The patient said she has a toothache and eye pressure and nasal congestion and
ringing in her ears.

41
Do not use a comma if each adjective or noun in a series is connected with
conjunction. The conjunctions used to connect items in a series will be either the
conjunction “and” or the conjunction “or.”

41
Here is a tip to help you decide if a comma is mandatory when dealing with items in a
series: If you can mentally replace the comma between adjectives with “and,” the
comma is necessary.

This is a well-developed, well-nourished, alert, and oriented Hispanic female

appearing much younger than her stated age.

If we take that same sentence and mentally replace “and” where the commas are,
the sentence makes sense.
This is a well-developed and well-nourished and alert and oriented Hispanic female
appearing much younger than her stated age.
Thus the commas are mandatory as they appear in sentence #1 on this slide.

42
Sentences that contain unusual word order are very common in medical
transcription. The three most prevelant types of unusual word order structures an
MLS will encounter are:
• Inverted sentence structure
• Interrupting phrases
• Adjectival phrases that come after the noun they modify

43
First let’s discuss sentences that have unusual word order due to an inverted
sentence structure.
Place a comma when the wording of the sentence causes it to have unusual word
order. For example:
What will happen after the chemotherapy ends, (comma) the patient does not
know.

But, if the sentence was worded in a more traditional manner, no comma is required:
The patient does not know what will happen after the chemotherapy ends.

Here is another example:

Consistent with his dehydration, (comma) the patient’s urine showed an increase of
specific gravity.

But, if the sentence was worded in a more traditional manner, no comma is required:
The patient’s urine showed an increase of specific gravity consistent with his
dehydration.

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As we explained earlier in this training module, an interrupting phrase quite literally
interrupts the flow of the sentence. Place a comma before and after an interrupting
phrase. An interrupting phrase is considered unusual word order. Here are some
examples. Each interrupting phrase is displayed in orange font on this slide.

The patient, age 72, presented with shortness of breath and dizziness.

There was decreased sensation in the lower extremities, greater on the left than the
right, to pinprick.

Patient is a 50-year-old female, well known to me through my office, who was

admitted because of a large right pleural effusion.

45
Our last type of unusual word order is when an adjective or adjectival phrase comes
after the noun in a sentence. Use a comma before an adjectival phrase that comes
after the noun it modifies.

DIAGNOSIS
Degenerative arthritis, left knee.
The comma replaces the missing words “of the.”

But when the adjective comes before the noun, no comma is used.
DIAGNOSIS
Left knee degenerative arthritis.

46
Adjectival phrases that appear after a noun are common particularly in a list.

PREOPERATIVE DIAGNOSES
1. Questionable osteomyelitis, right calcaneus.
2. Infection, right heel.
3. Nail puncture wound, right heel.

But when worded differently such that the adjective comes before the noun it
modifies, then no comma is required :

PREOPERATIVE DIAGNOSES
1. Questionable osteomyelitis of right calcaneus.
2. Right heel infection.
3. Nail puncture wound of right heel.

47
Often a sentence will contain multiple commas, but those commas are required for
different reasons. Consider the following example:

IMPRESSION
Chronic dementia, probably Alzheimer disease type, with superimposed delirium,
now resolved.

^ There is comma before and after the phrase in orange (probably Alzheimer type) as
it is an interrupting phrase.
^ There is a comma after “delirium” due to unusual word order. The comma serves to
replace the missing words “which is.”

48
Adjectives are describing words. They describe a noun by answering one of these
three questions: What kind is it? How many are there? Which one is it?

On incising the peritoneum, clear drainage was suctioned.

^ The adjective is “clear.” It describes what kind of drainage is present.

Adjectives are generally placed before nouns, to include nouns inside dependent
phrases and prepositional phrases. Let’s consider this example.

In her postoperative condition, she was at risk for myocardial infarction.

^ Both adjectives in this sentence are contained within a prepositional phrase and
serve to describe the object of the preposition. In the prepositional phrase “in her
postoperative condition” the adjective is “postoperative.” It describes what kind of
condition. In the prepositional phrase “for myocardial infarction,” the adjective is
“myocardial.” It describes what kind of infarction.

Note that the 3 common articles in the English language—the, a, an—are adjectives.

49
Now we will discuss a part of speech called an adverb.
• Adverbs modify verbs, adjectives or other adverbs.
• Adverbs often end in –ly.
• Adverbs may come before or after the word they modify.

Adv > Adj

Dad was extremely anxious before the MRI scan.
^ In this sentence, the adverb is “extremely,” and it modifies the adjective “anxious.”
In this instance, the adverb comes before the word it modifies.

V < Adv
The baby cried loudly after circumcision.
^ In this sentence the adverb is “loudly,” and it modifies the verb “cried.” In this
sentence, the adverb comes after the word it modifies.

Adv > Adv > V

The area around the tube site is more severely eroded.
^ In this sentence there are two adverbs. The first adverb, “more,” modifies another
adverb, “severely.” The adverbs “more severely” modify the verb “eroded.” Note
that the adverbs come between the verbs “is” and “eroded.”

50
Now let’s discuss how to punctuate adverbs.

Do not use a hyphen with compounds formed with adverbs ending in -ly.
The –ly adverb functions to modify another word in the sentence, not to serve in a
compound role.

The sentence in purple on this slide contains compound modifiers, and the
compound modifiers are hyphenated.
This is a well-developed and well-nourished patient.

However, if the sentence was cast using adverbs, then no hyphens are used.
This is a poorly developed and poorly nourished patient.

Here is another example.

The patient had highly complex symptoms that made it difficult to form a diagnosis.

A general rule of thumb is do not use a hyphen to connect any word that ends in the
letters “ly” to the word that follows.

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A verbal is a word formed from a verb but functioning as a different part of speech.
VERBALS include gerunds, infinitives, and participles. We will begin by discussing
gerunds.

GERUNDS are easy to spot; they end in “-ing” and function as nouns. On first look,
they appear to be verbs. Do not confuse gerunds with verbs.

Our first pair of sentences uses the word “walking” first as a gerund and then as a
verb.
S V
Walking in the park is refreshing.
The verb in the sentence is “is refreshing.” What is refreshing? Walking. Thus
“walking” is the subject of the sentence. The word “walking” is a gerund. It is being
used as a noun and is the subject of the sentence.

S V
She began walking the day after surgery.
In this sentence “walking” is the verb of the sentence. The subject is “she.” The word
“walking” is an action verb. The subject of the sentence performed that action,
walking.

S V

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Talking to strangers is dangerous.
The verb in this sentence is “is.” Dangerous is an adjective, providing more
information to what “is” is referring. What is dangerous? Talking. The word “talking”
is the subject of the sentence, and “talking” functions in this sentence as a gerund.

S V
The nurse is talking to the patient in bed #2.
In this sentence “is talking” is the verb.

When a word ending in –ing describes an action, it is a verb.

When a word ending in –ing is the subject doing the action, it is a gerund.

52
Another type of verbal is an infinitive. Infinitives are easy to spot; they generally
begin with the word “to” but function as verbs. Do not confuse them with
prepositions.

Our first pair of sentences will use the word “to,” first as an infinitive and then as a
preposition.
S V V
He was asked to schedule an appointment before Friday.

^ In this sentence the infinitive phrase “to schedule” is used as a verb. It provides
additional information about what he was asked to do. The words “to schedule”
provide an additional action on the part of the subject.

S V
We will go to the OR.

^ In this sentence, the phrase “to the OR” is a prepositional phrase. The verb is “will
go.” The prepositional phrase provides more information about where the patient
will go (to the OR), but it does not provide an additional action.

In the second pair of sentences we will again use the word “to,” first as an infinitive
and then as a preposition.

53
 S V V
The hospital paid for a display to advertise the new wing.
^
The verb in this sentence is “paid.” The infinitive is “to advertise.” It provides further
action on the part of the subject. The hospital paid to advertise.

S V
The paramedics took the patient to the ambulance.

^ In this sentence “to the ambulance” functions as a prepositional phrase. The verb
is “took.” The prepositional phrase “to the ambulance” provides a description of
where the patient was taken.

53
The last type of verbal that you may encounter in medical transcription is a
participle. A participle is a verbal that functions as an adjective (descriptor).

Perfumed scents trigger her allergies.

^ In this sentence, “perfumed” functions as an adjective. The verb is “trigger.”
The subject is “scents.” The word “perfurmed” is a participle as it serves as
an adjective, describing what type of scent triggers her allergies.

Her cologne perfumed the office.

^ In this sentence, “perfumed” functions as a verb.

A seasoned MT recognizes discrepancies.

^ In this sentence, “seasoned” functions as an adjective. It describes the type
of MT—a seasoned, or experienced, MT.

She seasoned the gravy.

^ In this sentence, “seasoned” functions as a verb. It expresses an action on
the part of the subject.

The opened wound was oozing blood.

^ In this sentence, “opened” functions as an adjective. The verb is “was
oozing.” The subject is “wound.” The participle “opened” is an adjective,
describing the type of wound.

54
He opened a large packet of medical records.
^ In this sentence, “opened” functions as a verb. It expresses an action on the
part of the subject.

With focused attention he found the RUL of the parathyroid.

^ In this sentence, “focused” functions as an adjective. It describes more
about the attention.

Next we focused our attention on the axilla.

^ In this sentence, “focused” functions as a verb. It expresses an action on the
part of the subject.

54
To review, A verbal is a word formed from a verb but functioning as a different part of
speech.
• Gerunds are words that end in “-ing” and function as nouns. Do not confuse
with verbs.
• Infinitives begin with “to” and function as verbs. Do not confuse with
prepositions.
• Participles are words that look like verbs but function as adjectives. Do not
confuse with verbs.
It is important to distinguish between these types of verbals (which are gerunds,
infinitives, and participles) versus verbs when deciding proper subject-verb
agreement in a sentence.

55
Compound modifiers consist of 2 or more words that function together as a unit and
express a single thought.
These one-thought modifiers are derived from (and take the place of) adjective
phrases and clauses.

Here are some examples. The left column depicts adjective phrases. The right
column depicts compound modifiers.

Adjective phrase Compound Modifier

an actor who is well known a well-known actor
a patient who is well developed a well-developed patient

Notice that when phrased as a compound modifier, the compound modifier if

hyphenated when it comes directly before the noun it modifies.

56
Deciding how to punctuate a compound modifier is a matter of noting where it falls
in a sentence.
Hyphenate the elements of a compound modifier that occur directly before the noun
they modify.
• This is a well-developed and well-nourished patient.
• The above-mentioned findings were noted.
• A biopsy-proven carcinoma.

Do not hyphenate these expressions when they occur elsewhere in a sentence.

• The patient is well developed and well nourished.
• The findings were as mentioned above.
• A carcinoma that was proven on biopsy.

57
A unique type of compound modifier involves adjectives in a series. When a series of
hyphenated adjectives has a common basic element and this element is shown only
with the last adjective in the series, insert a suspensive hyphen after each of the
incomplete adjectives to indicate a relationship with that basic element.

Patient presents with a 2- to 3-week history of swelling in the left leg.

The basic element is “week.” The number 2 has a hyphen immediately after it to
indicate that it is connected with the basic element of “week.” Instead of saying “a 2-
week to 3-week history,” the basic element is implied. Use a space after a suspending
hyphen, so 2 hyphen, space, 3-hyphen-week history.

Do not use a space if a comma immediately follows the hyphen.

Mom made appointments for the baby’s 2-, 4-, and 8-week followup visits.
The basic element is “week.” A hyphen is used after “2” and “4” to indicate that they
are connected with the word “week.” The comma comes immediately after the
hyphen with no spaces used.

(Item being modified is in red font, and basic elements are in green font.)

58
• Dashes are different from a hyphen.
• Dashes are used to give greater emphasis, to explain a statement, to set off a
parenthetical element, to replace a comma or comma pair.
• Dashes are not usually required in medical transcription. Use an alternative,
usually a comma, whenever possible.
• A hyphen (-) is made by pressing the hyphen key once.
• A dash (—) is made by pressing the hyphen key twice.
• There is no space either before or after a dash.

59
Dashes are used sparingly in transcription. Often, dictated dashes are edited to
commas.

Dictated: Diagnosis. Upper respiratory infection (dash) rule out pneumonia.

Transcribe:
DIAGNOSIS
Upper respiratory infection, rule out pneumonia.

If you have an account that insists upon verbatim (including punctuation directions),
then use the dictated dash, like so:
DIAGNOSIS
Upper respiratory infection—rule out pneumonia.

Notice that there is no space before or after the dash.

60
Apostrophes are used quite often in medical transcription. The primary reason for
the use of an apostrophe is to form a possessive.
To form the possessive of a singular noun NOT ending in an s sound, add an
apostrophe plus s to the noun.

Regular singular noun Singular Possessive

child child’s game
doctor the doctor’s advice
hospital the hospital’s rules
Mary Mary’s career
patient the patient’s temperature

61
To form the possessive of any noun ending in the letter s, place the apostrophe at the
end of the word, never within it.

Regular singular noun Singular Possessive

Mr. Hodges Mr. Hodges’ medication

If a new syllable is formed in pronunciation of a singular possessive, add an

apostrophe plus s.

Regular singular noun Singular Possessive

boss your boss’s approval
coach my coach’s training regimen
Mr. Marsh Mr. Marsh’s prescription

62
For a regular plural noun (one that ends in either s or es), simply add an apostrophe
to make a plural possessive.
Regular plural noun Plural Possessive
attorneys attorneys’ fee
physician physicians’ orders
agencies the agencies’ conflicting rules

For an irregular plural noun (one that does not end in s) add an apostrophe plus s to
make a plural possessive.
Regular plural noun Plural Possessive
women women’s slippers
children children’s toys

63
Another reason apostrophes are used in medical transcription is due to eponym
names.
An eponym is something named for a person.
The industry standard is to drop the apostrophe and the letter s from eponym names.

Let’s say the following sentence is dictated:

D: The patient has Alzheimer’s disease.
In accounts that permit minor edits, the preferred way to transcribe that sentence is
to drop the apostrophe plus s off the eponym name and transcribe:
T: The patient has Alzheimer disease.

If the following sentence is dictated:

D: There was a negative Babinski’s sign.
In accounts that permit minor edits, the preferred way to transcribe that sentence is
to drop the apostrophe plus s off the eponym name and transcribe:
T: There was a negative Babinski sign.

Note that on strictly verbatim accounts, you would transcribe the sentence exactly as
dictated and not edit out the apostrophe plus s.

64
Do retain the apostrophe and the letter s if the noun does not follow the eponym
name.
D: The patient has early Alzheimer’s.
T: The patient has early Alzheimer’s.

Notice the difference between this sentence compared to the sentence that was on
the previous slide where the noun immediately followed the eponym name. When a
noun follows the eponym name, drop the apostrophe and letter s.
D: The patient has Alzheimer’s disease.
T: The patient has Alzheimer disease.

65
The most common possessive plural in medical transcription involves units of time.

Singular noun: week

Form the possessive plural by adding apostrophe plus s.
The patient will be seen for followup in 1 week’s time.

Plural noun: weeks

Form the possessive plural by adding apostrophe only. The apostrophe is placed after
the letter “s.”
The patient will be seen for followup in 2 weeks’ time.

66
• Another type of punctuation you will encounter in medical transcription are
quotation marks.
• Use quotation marks to denote the exact words of a patient as specified by the
dictator.
• When the quote material represents an independent clause (meaning it could
stand alone as its own sentence), use a comma before the quote, capitalize the
first word of the clause, and place the final period inside the ending quotation
mark.
• This type of quote occurs most often in literature, less often in medical
documents.

D: The patient states quote I feel lousy unquote.

T: The patient states, “I feel lousy.”

Notice that the period goes inside the ending quotation mark.

67
• When the quote material represents a word, phrase, or dependent clause, do not
place any comma before the opening quote and do not capitalize the first word in
the quoted material. Place any punctuation (commas, final period) inside the
ending quotation mark.
• This type of quote is far more prevalent in medical documents.

D: She states she is allergic to ragweed and quote that yellow plant unquote that
grows in the field behind her house.

T: She states she is allergic to ragweed and “that yellow plant” that grows in the field
behind her house.

68
• A colon is used in the announcement of what is coming next. It is placed after a
word introducing an explanation, a series, a list, or an example. It is also used after
the salutation in a letter.
• MTs most commonly use colons after a subheading.

D: Heart regular rate and rhythm.

T: Heart: Regular rate and rhythm.

D: Neurologic strength was 5 out of 5 in both upper and lower extremities.

T: Neurologic: Strength was 5/5 in both upper and lower extremities.

(Note that you will format subheadings in the PE section of a report as per your
account specific directions. Some accounts request that subheadings be typed in all
capital letters, while other accounts only want major headings in all caps and
subheadings formatted in mixed case. Always consult the account specific directions
for your account to ensure that you are formatting headings and subheadings as per
client’s guidelines.

69
When the narrative begins on the same line as a major heading, use a colon after the
heading.
CHIEF COMPLAINT: Left arm numbness.

Note that it is more common for a heading to be formatted on a line by itself with the
narrative beginning underneath. Do not use a colon after a heading when it is on a
line by itself, unless your account specific directions state to format otherwise.

CHIEF COMPLAINT
Left arm numbness.

70
Place a colon after a complete phrase that introduces a series.
Her medications include all of these: hydrochlorothiazide, Xanax, Pravachol, and
Coreg.

His symptoms include all of the following: diaphoresis, nausea, vomiting, and shaking
chills.

Do not use a colon after an incomplete phrase.

Her medications include hydrochlorothiazide, Xanax, Pravachol, and Coreg.

His symptoms include diaphoresis, nausea, vomiting, and shaking chills.

71
Use colons to express hours and minutes.
The patient arrived at the ER at 1:45 a.m.

Do not use a colon with military time.

The patient arrived at the ER at 0145 hours.

Use colons to express a ratio (a mathematical expression showing the relationship of

one part to another).
The wound was infiltrated with lidocaine with 1:100,000 epinephrine.

Note that only the ratio value uses the colon. The actual test name uses a hyphen or
virgule.
Albumin-globulin ratio was 2:1.

72
There is only one instance in which a semicolon would be required punctuation:
When there is internal punctuation present with items in a series.
Here is an example:

Discharge medications include Lasix 20 mg p.o. q.a.m.; metoprolol 50 mg p.o. daily;

Humulin N, 10 units at breakfast, 15 units at lunch, and 20 units at supper; and
Combivent inhaler 2 puffs p.r.n.

Since each medication instruction already contains internal punctuation, a semicolon

is required between each of the items (each separate medication section) in the
series.

General rule of thumb: Use semicolons very sparingly.

Apart from internal punctuation in a series, in almost all other cases, a semicolon
could be replaced by a period to create two separate sentences.

73
Always end a sentence with a period.
Remember that when transcribing a numbered list, each item in the list is considered
a sentence, and it must end with a period. Even 1-word sentences must end with a
period.

DISCHARGE DIAGNOSES
1. Chronic obstructive pulmonary disease.
2. Hyperthyroidism.
3. Hypertension.

74
Do not use periods in professional titles or certifications.
• The handouts were created by Diana Gish, CMT, AHDI-F.
• Please send a copy to William Barnes, MD, at his Pine Avenue address.

If a sentence ends with an abbreviation that already contains a period, do not add
another period.
The patient arrived at the ER at 1:45 a.m.
Since there is already a period after the “m” in “a.m.” do not add another period. The
period after the “M” also serves to end the sentence.

She was instructed to take Tylenol p.r.n.

Since there is already a period after the letter “n” in the abbreviation “p.r.n.” do not
add another period The period after the “n” in p.r.n. also serves to end the sentence.

75
Most drug abbreviations contain periods.
Always consult your account specifics and the Nuance Transcription Guidelines
(NTSG) to ensure you have the correct spacing and punctuation.
p.r.n. q.i.d. q.a.m.
q.6 h. t.i.d. b.i.d.
q.6 hours q.4-6 h. q. day

Remember that dangerous abbreviations must be edited. See your account specifics
and the NTSG.
Dictated Transcribe
q.d. Daily
q.h.s. nightly or at bedtime

76
Always ensure you have the correct capitalization, spacing and punctuation. An
abbreviation may contain the same letters but mean different things depending upon
the capitalizing or punctuation.
t.i.d. three times a day
TID transient ischemic dilation
tubal inflammatory damage

q.i.d. four times a day

QID Quantum inflation device

77
To make an abbreviation plural, simply add the lowercase letter “s” with no
apostrophe when the abbreviation consists of all capital letters.

Singular Plural
WBC WBCs
DTR DTRs
CBC CBCs

The CBC showed elevated WBCs.

DTRs were +2 and equal bilaterally.
A series of CBCs was ordered.

The lowercase letter “s” added to the end of an acronym that is in all caps indicates
that it is a plural. In all of these cases, the acronym happen to be 3 letters long. The
lowercase letter s designates a plural of these 3-letter acronyms. Do NOT add a
capital letter “S as then that would change the actual meaning to a 4-letter acronym.

78
To make an abbreviation plural when the abbreviation consists of all lowercase
letters, add an apostrophe plus the letter “s.”

Singular Plural
wbc wbc’s

The CBC showed elevated wbc’s.

Lowercase abbreviations do not occur often in medical reports apart from metric
measurements. Use the same abbreviation format for both singular and plural metric
abbreviations.
The patient received 1 mg of Demerol.
The patient received 4 mg of Demerol.

79
Use an apostrophe plus “s” to form the plural of an abbreviation that consists of a
single letter.

The EKG showed inverted T’s.

The nurses were instructed to maintain strict I’s and O’s.

Use an apostrophe plus “s” to form the possessive of an abbreviation.

Please refer to AHDI’s paper on verbatim transcription.

The AMA’s policy on credentialing has been modified.

80
In this module, we have covered the following topics:
• Basic parts of speech
• Subject-verb agreement
• Complete versus dependent phrases
• Unusual word order
• Punctuation rules as they pertain to transcription

The most difficult portion of a medical report to punctuate involves laboratory data.
Since the punctuation required when dealing with lab data is complex, see the
separate module dedicated to the punctuation of laboratory data.

81
Thank you for completing the English Grammar and Punctuation Training Module. If
you have any questions regarding this training module, please do not hesitate to
contact the Nuance Transcription Services Training Department at
NTS_Training@Nuance.com.

82