Guidelines pertaining to the Template, Header, Formatting, and Alignment of SMA files.
All new SMA files have the template „Progress Note M2‟. This template is automatically
opened on get file operation. Check whether „Preliminary Report‟ is entered at the
bottom of the file just before signature line. If not change template (Alt+T) to „Progress
Urgent care files do not carry „Preliminary Report‟ at the bottom. (UC files are done
inhouse only and it is indicated in the footer whether the file is UC or Progress Note)
Short cut key for change template is (Alt+T)
Header details will be automatically inserted on get file operation. If not, use the Query
Enter the Visit No from the Demographic info into in the box after “Visit No” in the
query wizard and click „Execute‟. You can also click the "Visit No" box and just use
Ctrl+V or Shift+Insert to automatically enter this number. Double click on the details
and the header will automatically be inserted. The MR No from the file name or the
dictated MR NO can also be used for querying, but remember to delete any zeros in the
beginning of the number before typing in the “MR NO” box.
If query operation comes up with multiple listing choose by file date.
If query operations yields old details i.e. Old visit dates. Double click and add the header
and then change the „Date of Visit:‟ to the file date in the header. Do not forget to change
this date in the footer also.
Finally, if the query yields no listings do not manually fill the header. Leave it as such
and do not type „No header‟
If a discrepancy between what is listed and what is dictated is encountered, make a note
of it just above the subjective and outside the header block preceded and proceeded by 2
E.g. **The doctor dictates a different DOB**
**Dictated as male patient in text**
**Dictated Mr No is ______**
The Font of the header is Courier 12. You can double click the header part, select all
(Ctrl+A), and change this if required to.
Urgent Care file headers will not be available. They must be queried. (UC files are done
FORMATTING and ALIGNMENT
The formatting is set in the template already, but all MTs must know the specifics just in case
there is a glitch and you need to do it manually.
SMA file font must be Courier 12 throughout. Exercise caution when copying and
pasting from old samples.
SOAP format is used for SMA files.
Give 1 tab after S: O: A: and P:
Do not use the numbering button to number items in Plan and Assessment, as this does
not give the client specified alignment in the mentioned sections. Instead, type the
numbers out and use tabs and the ruler bar to align. The top indent (first line indent) in
the ruler bar must be at 0 and the bottom indent (hanging indent) at 0.5. See sample files
The signature line must have the name of the doctor as in the doctors list. Some
templates have spelling errors and incomplete name. Review and correct your templates
For the sake of uniformity, let us use M.D., D.O., PA-C, PA, APN, APN-C, R.N., N.P.,
DPM. (Note the periods and hyphen)
The MT ID block must look like this:
DD is the date of dictation. This is the date in the file name.
DT is the date of transcription and must be the next date to the file date.
E.g. DD: 07/03/2003
Remember that the files are going to be printed at clinic in the exact alignment and
formatting that we send it. Avoid unsightly spaces in between and in the left margin.
Our formatting and aligning of the files are final. Check alignment in the print layout
CAUTION WHILE SENDING FILES.
T+E MTs must exercise extreme caution to avoid sending doubt files as edited because
with T+E operation privileges this is an easily made mistake. Do not just strike the enter
key. Look at the listing carefully and then click „send‟.
The above caution applies to the editors too. If by chance a mistake is made resend the
file immediately or report.
Doubt files must be flagged **Doubt** just above Subjective.
Transcribers must avoid resending their files.
Transcribers must not send any files to corrupt. This operation is to be done by the
editors after verification.
REMINDER TO EDITORS
Report all addendum files.
Henceforth appropriate comments must be entered in the comment box while sending
Use the following comments as appropriate
“Corrupt wave” for inaudible wave.
“Incomplete” when a few lines are dictated and there is an obvious wave cut off.
“Blank file” when no text is dictated.
“Test file” when you hear “Testing, testing, testing...”
“Canceled dictation” when the doctor asks to cancel the dictation.
“Addendum” If the addendum file has already been appended to the original file.
All corrupt files must be flagged **Corrupt File** inside the file before sending.
In case of the addendum instead of typing **Corrupt File** inside the file type
**Addendum file added to previous**