Medical Reports and the Foreign Language of Medicine

By Connie Limon

Techniques used by physicians to gather data for a diagnosis consists of two procedures known as:

• History Examination

• Physical Examination

Combined, these two make the physician report of “history and physical examination.” The history portion is the patient’s own description of his or her experiences, observations, symptoms or complaints of illness. The physical examination consists of a process whereby the physician seeks and observes objective changes and abnormalities, which are the signs of illness.

In a typical case, a skillfully obtained history provides a larger number of diagnostic clues that are more useful and specific than the actual physician’s physical examination.

To get the most out of your doctor visit, be well prepared with a thorough list or report describing your illness or ailment. I have written detailed reports for personal use, and granted, a physician may not always need such details as I have provided, but…..in one case in particular I think without my detailed report I would have not gotten the expert treatment as I eventually got. Sometimes, you have to really “jar” the minds of the physician to really get out of them the diagnosing and treating skills specific to your particular illness or ailment.

By definition, the physical examination includes those procedures performed directly by the physician as he relies on his own senses, with the aid of hand-held instruments. X-rays, laboratory studies, electrocardiography and electromyography, various scans or other techniques may eventually be absolutely essential to make a precise and accurate diagnosis. These are not considered part of the physical examination.

The word “diagnosis” in medicine is an interesting word to think about what it means. First, it is the intellectual process of analyzing, identifying, or explaining a disease. The diagnosis forms the subject matter and means the explanation proposed for a patient’s problems. Physicians speak about arriving at a diagnosis or of making a tentative diagnosis. So that the history and physical examination report is a physician’s report of his findings during the interview with a patient and his own examination with a goal of moving toward a diagnosis for this patient.

Upon dictating the history and physical report, the physician will include patient’s name, patient’s date of birth and other identification information such as hospital number or private practice number, etc. The medical transcriber must be very careful that he or she transcribes the patient identification information accurately.

The medical report of a thorough history and physical contains more negative than positive statements. This is due to the fact that a physician is not concerned only with compiling a list of abnormalities about the patient. He or she must establish a complete picture of the patient’s condition; therefore, he must also say what common or relevant symptoms and signs are not present.

The language of medicine is like a “foreign language” that a Medical Transcriptionist must learn as well. It is sort of like while in Rome, you must be like the Romans and speak and understand as the Romans. When transcribing medical dictation a Medical Transcriptionist is in the foreign land of “Medicine,” and he or she must or will learn the language of this foreign land.

The language in which a physician writes or dictates a history and physical contains many recurring terms, phrases, and formulas. Some of these terms and phrases are formal medical terminology, while others are highly informal, perhaps regional, institutional, or even individual, and do not appear in conventional medical reference books. For these types of phrases and terms, a Medical Transcriptionist usually learns them as she goes.

Of course, the History and Physical medical report is not the only medical document that a Medical Transcriptionist produces in the daily schedule of Medical Transcription. There are many more reports and much more to learning the language of medicine than meets the eye.

Formal education is definitely a “must” in today’s Medical Transcription work environment. You will to start your own personal library of books and references along with notebooks of these out-of-print types of words and phrases physicians use when they dictate.

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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.

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