By Connie Limon
Medical report formats and styles vary according to your location. The examination portion of a routine History and Physical report might be transcribed in block paragraph form or with indentations, hanging paragraphs, with subheadings in all capitals, or subheadings in upper and lowercase letters. There is no real set in stone format or style. You will need to follow the instructions of your employer about report formats and styles.
Sometimes the physician’s dictating style determines the appropriate format, or the medical facility you work for may mandate certain formats as standard.
The medical transcriptionist is usually allowed to add headings and subheadings to a dictated report as appropriate. While transcribing, the medical transcriptionist needs to be alert for when to insert an appropriate heading that is not dictated but is vital to the report. An example of this might be the dictator does not dictate such headings as “Diagnosis,” or “Final Diagnosis,” or “Discharge Summary.” The Medical Transcriptionist should insert these types of headings when the dictator fails to dictate them.
If you find yourself inserting appropriate headings not dictated by the dictator, you will need to flag the report to the attention of the dictator so that the diagnosis or final diagnosis can be stated if the information is left out. Of course, if only the heading is left out, you would not need to flag the report.
If you come across a dictator that uses abbreviations for report headings such as CC for Chief Complaint or HPI for History of Present Illness, always spell these headings out in full as you transcribe.
It is not uncommon for a physician to finish dictating the Physical Examination section of a Discharge Summary and start to dictate laboratory test results or x-ray results without dictating a heading for this new section. If this occurs, the appropriate course of action on the part of a medical transcriptionist is to paragraph after the Physical Examination and insert the appropriate paragraph heading such as “Laboratory Data,” or “Laboratory and X-ray Data,” before transcribing the actual data.
Sometimes a physician will dictate the singular form “diagnosis” and then list several diagnoses. The heading is appropriate to use either “Diagnosis” or “Diagnoses.” Diagnoses are usually listed vertically as a universal rule regardless of where or who you work for. This provides greater ease in reading.
A medical transcriptionist may wish to place numbers before a long list of diagnoses, regardless of whether or not the numbers are dictated by the physician. If the physician begins the diagnosis section dictating numbers and then only dictates one diagnosis, do not place a number in front of this one diagnosis. If the dictator dictates a long list of “anything” and loses track of his or her numbers, the medical transcriptionist should always transcribe the correct list instead.
Many dictators will dictate when to begin a paragraph. The medical transcriptionist should insert the paragraphs as dictated unless of course it is not grammatically correct to proceed as the dictator dictates the paragraphs. Paragraphs may also be added when the dictator fails to dictate one and it would be appropriate to break up long reports or to set up a new heading such as to separate “Findings” from the “Operative Procedure.” Some dictators may dictate “new line,” which actually means “new paragraph.”
Many hospitals, clinics, and physician offices store standard format outlines for each type of report dictated on the computer’s memory as templates, which are easily pulled up by the medical transcriptionist. This procedure has introduced greater conformity in format style within an institution and makes it absolutely painless for the medical transcriptionist to have to make adjustments and remember each format for each type of report dictated.
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© 2007 Connie Limon All Rights Reserved
Written by: Connie Limon, Medical Transcriptionist. Visit us at http://www.aboutmedicaltranscription.info/ for more information about the unique and rewarding career choice of Medical Transcription. Join Camelot Articles http://www.camelotarticles.com/ and submit your original articles for website promotion and backlinks.
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Tuesday, March 11, 2008
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