Medical Reports

A variety of medical reports concerning patients may be transcribed by medical transcriptionists. On a few occasions, a physician may want his or her private secretary to transcribe some of these reports; and in some medical facilities, the department secretary will do the transcribing.

A variety of medical reports concerning patients may be transcribed by medical transcriptionists.

Introduction of Medical Reports:

On a few occasions, a physician may want his or her private secretary to transcribe some of these reports; and in some medical facilities, the department secretary will do the transcribing.

For instance, the pathology department may have laboratory reports and autopsy reports and transcribed right in the department laboratory reports and auto spy report transcribed write in the department.

Consultation reports may be transcribed in the hospital or physician’s office, and medico-legal reports are usually done in the private medical office. Private transcription agencies do all kinds of medical typing and transcribing.

Accuracy and readability are the most important factors emphasized in the format. All headings and subheadings must follow the same format, so it is important to determine how you will set up the report before you begin typing. Topics of equal importance are given equal emphasis by using capital letters, lower case letters, spacing, underlining, centering, and so forth.

The general guideline to follow is to transcribe exactly the sequence that is dictated trying to pick out the emphasis words for measure headings and those requiring less emphasis as subheadings. In some Institutions, forms with pre-printed headings require that you reformat the dictation so that it is typed in the sequence given on the forms.

Discharge Summaries

A discharge summary (clinical resume or final progress note) is required for each patient who is discharged from a hospital.

It contains the same information that is found in the patient’s history and physical with the addition of the admitting and discharge diagnosis; operations performed; laboratory and X-ray studies; consultants; hospital course; and, finally the condition of the patient at the time of discharge with the medications on discharge instructions for continuing care, therapy, and possibly follow-up postoperative office visit date.

The condition of the patient on discharge should be stated in terms that permit a specific measurable comparison with the condition on admission, avoiding the use of vague terminologies, such as “improved.” If a resident or intern (house staff physician) dictates the discharge summary, it is usually approved by the attending physician (attending staff physician).

If authorized in writing by the patient or a legally qualified representative, a copy of the discharge summary should be sent to any known medical practitioner or medical facility responsible for follow-up care of the patient.

OPERATIVE REPORTS

Whenever a surgical procedure is done, an operative report should be dictated or written in the medical record immediately after surgery. It should contain a description of the findings the technical procedure used, the specimens removed, the preoperative and postoperative diagnosis or diagnosis, the type of operation performed, and the name of the primary surgeon and any assistants. The body of the report is a narrative of the procedure and finding and contains the type of anesthetic, incision, instruments used, drains, packs closure, and sponge count.

The completed operative report should be authenticated by the surgeon and filed in the medical record as soon as possible after surgery. When there is a transcription or filing delay a comprehensive operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for other physicians who may be attending the patient.