Get to Know the Different Types of Medical Transcription Reports Healthcare practices may have to deal with diverse records such as discharge summary, lab reports and more that require accurate medical transcription.
Hospitals, specialty practices and clinics create diverse reports each day related to the patient’s condition, diagnosis and treatment. Such reports are also for future reference and information purposes. Providers require accurate transcripts for the recordings they make during consultation. Such transcripts play a key role in creating the patient’s medical history which is used for reference by healthcare providers, medical practices, insurance companies, and lays a foundation for future patient visits. To ensure accurate and reliable transcription of dictated notes, healthcare providers need to choose a professional medical transcription service.
www.medicaltranscriptionservicecompany.com
918-221-7801
The different types of medical transcription reports are History and Physical report
Dictated by physicians when a patient is admitted to the hospital
Includes main concern, the patient’s current illness, medical, social and family medical history
Complete physical examination of the patient, admission diagnosis and a treatment plan
Consultation report
Dictated by the physician to whom the admitting physician has referred the patient
Includes a small description about the patient’s illness and physical exam based on consultation
Concludes with the physician’s impression and treatment plan
Operative report Dictated by the operating physician, this report includes a detailed description about
Operative procedure
Pre-operative and post-operative notes
The type of surgery
Name of the surgeon and anesthesiologist
Radiology report
Dictated by the radiologist once the diagnosis and radiology procedures are completed
Includes the radiologist’s findings on x-rays, CT scans, MRI scans, nuclear medicine procedures and more
Pathology report
Dictated by the pathologist and includes the microscopic findings of the sample
www.medicaltranscriptionservicecompany.com
918-221-7801
Laboratory report
Includes the findings of examinations of bodily fluids such as blood levels and urinalysis
Rarely dictated separately but often included in the H&P, consultation or discharge summary
Hospital report
Includes all the reports that were dictated in the hospital
Discharge summary
Dictated by the physician at the end of the patient’s stay at the hospital
Includes all reports right from the admission of the patient until discharge
The report ends with a detailed plan for the patient
Office reports
Created in a medical practitioner’s office, not treated as hospital reports
Includes initial evaluations, letters to referring physicians, chart notes and more
It is very important for these medical transcripts to be error-free, as they contain important medical data of patients for future reference. A reliable, HIPAA-compliant medical transcription company can support any medical specialty in transcribing audio files with utmost accuracy, that too at affordable rates. Providers have to go through these transcripts and charts to review patient evaluations and take proper treatment decisions. Even a minor error in the transcript or a misspelling can cause major health issues or even lead to death.
www.medicaltranscriptionservicecompany.com
918-221-7801