Types of Medical Reports Medical Transcriptionist's Transcribe Part I

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:

• Office chart notesn • Lettersn • Initial office evaluationsn • 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:

• History and Physical Examinationsn • Consultation Reportsn • Operative Reportsn • 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 problemn • Physical findingsn • Physician’s plan of treatmentn • 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:

• Subjectiven • Objectiven • Assessmentn • Pla

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.

Continued in Part II

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