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Tuesday, January 6, 2009


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


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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