Medical Transcription Services Company

Reports are presented in two basic categories, outpatient and inpatient. There are also six major types of hospital medical reports or records, and they make up the majority of all hospital dictation. They are as follows:

• the History and Physical Report(H&P);
• the Discharge Summary (DS);
• the Operative Note or Report (OP),
• the Consultation Report (CONSULTS). These are the basic four you will often hear about in the future; plus, there are two more
• the Pathology Report (PATH); and
• the Radiology Report (x rays or radiographs).

However; medical offices usually use only two types of medical reports or records (also called charting), and they are as follows:

• Chart Notes (including H&Ps), and
• letters or correspondence.

The Peculiar Dictation section is provided for fun (though based on real reports): These reports include doctors office notes:

• chart notes are usually brief notes about the patient and his/her problems and/or progress;
• history and physicals, which are a story about the patients current problem, past history, family history, and a complete physical examination, laboratory data, radiological and pathology reports; and
• correspondence, which contains patient workups, treatments and follow ups to referring doctors.

The outpatient records are generally the least terminology complicated (less intense vocabulary than, for instance, surgery) and these reports focus on a doctors specialty, e.g., obstetrics, orthopedics, etc. Thus, these notes deal with a more narrowed single specialty vocabulary (though a family practitioner or a clinic, which has several specialists, would expand that vocabulary considerably). These records are developed by the doctor in the hospital for the patients medical record and include history-physicals (see above), operative I reports, laboratory and pathology data, cardiology and radiology findings, and discharge summaries which incorporate significant history and physical information, and all of the other report types in summary form. They also discuss the course in the hospital, the outcome and diagnoses, and the discharge plan(s). Discharge summaries are in effect the closing chapter on a patients stay at a hospital and are done at the time of the patients discharge from the care facility. This dictation and transcription is done for every hospital admission. In the event of death, an Autopsy or postmortem report may be done, and the the findings are dictated related to detailing the cause of death. The records in this section were excerpted from actual dictation, which had some hilarious interpretational possibilities. A transcriptionist or individual involved in medical records is exposed to bizarre expressions and errors in dictation and even written records, which should be fixed. However, the license to do major editing is neither advisable (with the exception of simple grammatical changes) nor permissible - keeping in mind that the record is a legal written document whose originator is responsible for it. At times, such editing is a difficult job, if not downright impossible (and sometimes dangerous). We hope you will get a chuckle after your long and sometimes arduous progress through the other report sections.

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