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