| The History and Physical Examination
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| | actual dictation includes: -Preoperative
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| (H&P) is generated shortly before or
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| | diagnosis -Postoperative diagnosis -Title
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| after a patient is admitted to the
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| | of operation -Findings -Procedure
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| hospital. This report usually contains:
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| | Dictation of the procedure includes:
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| -Chief complaint or presenting problem
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| | -Detailed description of the operation
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| -History of present illness which are the
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| | itself -Anatomic landmarks -Surgical
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| events leading to the patient's
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| | instruments used -Suture materials used
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| hospitalization -Past medical history
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| | to close the incision -Estimated blood
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| which is medical and surgical problems
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| | loss -Complications -Condition of patient
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| from childhood to the present,
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| | at end of procedure -Sponge and needle
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| medications, and allergies -Family
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| | count at end of procedure -Tourniquet
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| History which is the medical condition of
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| | time if applicable -Blood and fluids
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| parents and other family members -Social
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| | administered -Drains placed -Medications
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| history which is the patient's
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| | given -Some surgeons will also dictate a
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| occupation, lifestyle, and habits -Review
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| | postoperative plan The discharge summary
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| of systems which is the medical condition
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| | is generated when the patient is ready
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| of the patient's major organs -Physical
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| | for discharge from the hospital. It is
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| examination Emergency department reports
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| | the medical report that summarizes the
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| are much like the initial office
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| | patient's course in the hospital. Length
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| evaluation with the exception of the
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| | of this medical report depends upon how
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| patient is seen and treated in an
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| | long the patient remained in the
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| emergency department of a hospital or
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| | hospital. Most discharge summaries
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| acute care clinic. Usually dictated are:
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| | include: -A summary of the admission and
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| -Presenting complaint -Present illness
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| | discharge diagnoses -Procedures or
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| -Physical examination -Course of
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| | operations performed if any -Brief review
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| treatment Consultation reports result
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| | of the patient's history -Physician's
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| when one physician requests the services
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| | findings on physical examination -A
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| of another, usually a specialist, in the
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| | report of laboratory work performed and
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| care and treatment of a patient. The
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| | pertinent findings -The patient's
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| consultation report usually contains the
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| | hospital course -Discharge medications
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| sub headings of: -Brief history of the
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| | -Discharge plan or disposition As you can
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| present illness -Findings -Pertinent
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| | see from Part I and Part II of Types of
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| laboratory work -Working diagnosis or
| |
| | Medical Reports Medical Transcriptionists
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| impression -Recommended course of
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| | transcribe, they are very detailed and
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| treatment A consultation report may be
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| | will utilize your love of words and
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| dictated in letter format and transcribed
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| | medical references to the absolute
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| on physician office stationery or the
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| | maximum. They contain the foreign
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| medical facility or on preprinted
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| | language of Medicine, which now has
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| consultation forms. The operative report
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| | become the language of the Medical
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| is generated after a surgical procedure
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| | Transcriptionist as well. This article is
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| is performed. It is a detailed
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| | FREE to publish with the resource box. ©
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| description of the operation. Surgical
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| | 2007 Connie Limon All Rights Reserved
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| procedures occur in: -Hospitals
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| | Connie Limon, Medical Transcriptionist.
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| -Outpatient surgery centers -Occasionally
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| | Visit us at for more information about
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| in physician's office The operative
| |
| | the unique and rewarding career choice of
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| report usually begins with information
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| | Medical Transcription. Visit Camelot
|
| obtained from: -Written records -Includes
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| | Articles for a variety of FREE reprint
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| date of operation -Includes duration of
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| | articles for your newsletter, web sites
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| anesthesia and operation times -Names of
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| | or blogs.
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| the operating surgeon and assistants The
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| |
|
