MEDICAL TRANSCRIPTION- INTRODUCTION-TYPES OF MEDICAL REPORTS-1-LESSON 30

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There are a variety of medical reports created every day in physician offices, clinics, and hospitals. A Medical Transcriptionist needs to be familiar with the medical reports dictated in each work setting.

Types of reports dictated in private physician practice include:

1. Office chart notes

2. Letters

3. Initial office evaluations

4. History and physical examinations

Types of reports dictated in hospitals and medical centers are numerous. The reports include dictations from a basic four which are:


1. History and Physical Examinations

2. Consultation Reports

3. Operative Reports

4. Discharge Summaries


In addition to the above reports emergency department reports, hospital progress notes and diagnostic studies are often also dictated.


The chart note is also called progress note or follow-up note is dictated by the physician after talking with, meeting with, or examining a patient usually in an outpatient setting. Progress notes or chart notes are also commonly dictated on hospital inpatients.


The chart note varies in length from one sentence to one or more pages and contains:
A concise description of the patient’s presenting problem• Physical findings• Physician’s plan of treatment• May also include laboratory tests results
Doctors use numerous formats for dictated chart notes. The SOAP format is common. SOAP stands for the headings of:


S- for Subjective

O-for Objective

A-for Assessment

P-for Plan


Physicians frequently dictate letters to communicate patient information to other physicians, insurance companies, and government offices. A Medical Transcriptionist will need to be familiar with the various standard business letter formats. Employers sometimes express a preference for a specific letter format. Most commonly used is the full-block format with the parts of the letter lined up on the left margin.


The initial office evaluation is dictated after the physician sees a patient for the first time and contains about the same information as the history and physical examination. However, a physical examination report in an initial office evaluation may be limited to specific areas of disease.


This subject continues in the next lesson TYPES OF MEDICAL REPORTS-2

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