MEDICAL TRANSCRIPTION-TYPES OF MEDICAL REPORTS-2-LESSON 31
The HISORY AND PHYSICAL (H&P) is generated shortly before or after a patient is admitted to the hospital. This report usually contains:
1. Chief complaint or presenting problem
2. History of present illness which are the events leading to the patient’s hospitalization
3. Past medical history which is medical and surgical problems from childhood to the present, medications, and allergies
4. Family History which is the medical condition of parents and other family members• Social history which is the patient’s occupation, lifestyle, and habits
5. Review of systems which is the medical condition of the patient’s major organs• Physical examination
EMERGENCY DEPARTMENT REPORTS are much like the initial office evaluation with the exception of the patient is seen and treated in an emergency department of a hospital or acute care clinic. Usually dictated are:
1. Presenting complaint
2. Present illness
3. Physical examination
4. Course of treatment
CONSULTATION REPORTS result when one physician requests the services of another, usually a specialist, in the care and treatment of a patient. The consultation report usually contains the sub headings of:
1. Brief history of the present illness
2. Findings
3. Pertinent laboratory work
4. Working diagnosis or impression
5. Recommended course of treatment
A consultation report may be dictated in letter format and transcribed on physician office stationery or the medical facility or on preprinted consultation forms.
OPERATIVE REPORT is generated after a surgical procedure is performed. It is a detailed description of the operation. Surgical procedures occur in:
1. Hospitals
2. Outpatient surgery centers
3. Occasionally in physician’s office
The operative report usually begins with information obtained from:
a) Written records
b) Includes date of operation
c) Includes duration of anesthesia and operation times
d) Names of the operating surgeon and assistants
The actual dictation includes:
1. Preoperative diagnosis
2. Postoperative diagnosis
3. Title of operation
4. Findings
5. Procedure
Dictation of the PROCEDURE NOTE includes:
1. Detailed description of the operation itself
2. Anatomic landmarks
3. Surgical instruments used
4. Suture materials used to close the incision
5. Estimated blood loss
6. Complications
7. Condition of patient at end of procedure
8. Sponge and needle count at end of procedure
9. Tourniquet time if applicable
10. Blood and fluids administered
11. Drains placed
12. Medications given
13. Some surgeons will also dictate a postoperative plan
The discharge summary is generated when the patient is ready for discharge from the hospital. It is the medical report that summarizes the patient’s course in the hospital. Length of this medical report depends upon how long the patient remained in the hospital. Most discharge summaries include:
1. A summary of the admission and discharge diagnoses
2. Procedures or operations performed if any
3. Brief review of the patient’s history
4. Physician’s findings on physical examination
5. A report of laboratory work performed and pertinent findings
6. The patient’s hospital course
7. Discharge medications
8. Discharge plan or disposition
We now have seen in detail about the details of types of medical transcription reports in common. In the next lesson, we will see more COMBINING FORMS..OK
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