Get to Know the Different Types of Medical Transcription Reports

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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.

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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

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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


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