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