Report Types in Medical Transcription

HISTORY AND PHYSICAL

This type of report is usually only typed up in a hospital setting. These are generated upon patient admittance the hospital and are used for reference throughout the hospital stay. Therefore, they are rarely contracted out for transcription outside the hospital. Their function is primarily to provide background information on new patients and outline what is planned for the hospital stay.

- Physical examination is generally given with a history and physical

DISCHARGE SUMMARY

A discharge summary is required for every patient formally admitted to the hospital. Ideally it is dictated the day of discharge or the day after a patient is discharged. It contains all of the information found in the history and physical, plus the hospital course and discharge plans.

CONSULTATION

A consultation is done when a physician other than the attending physician examines and/or runs tests on a patient.

OPERATIVE REPORT

An operative report is generated upon completion of any type of surgical procedure. These are required for same day surgeries as well as on admitted patients.

SOAP format

The SOAP format is used in several different types of medical reports. It is the most common method of formatting routine or problem-oriented doctor visits. It is also used for physical therapy and other types of medical specialties.

History (subjective), Exam (objective), Diagnosis (assessment), and Plan.

RADIOLOGY REPORT

A radiology report is any type of an x-ray examination. These include chest x-rays, backs, hips, arms, feet, toes, fingers, skull, CT, and MRI examination, upper GIs, ultrasounds, bone age tests, etc. They follow a simple format.

PATHOLOGY REPORTS

Pathology reports are done on tissue specimens, such as a removed appendix or tonsils and adenoids, a biopsy specimen for cancer, an aborted fetus, etc. Autopsies are also pathology reports.