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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 ...

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 outpatien...