There are several types of medical transcription reports. These have specific formats and make things easier for the physicians accessing them for followups and case study. Let us have a look at them:
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient’s chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD. It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way. Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient’s progress.
Letters are usually dictated by a physician to whom the admitting physician has referred the patient. Therefore, the consulting physician is usually a specialist in an area other than the admitting physician. Sometimes consultations are requested for second opinions. Consultation reports usually include a brief history of the patient’s illness and a specific physical exam depending on the particular type of consultation requested. The report may also include laboratory or x-ray findings. The report usually ends with the consulting physician’s impression and plan, and sometimes a comment from the consulting physician thanking the admitting physician for the referral.
Discharge summaries are dictated by the admitting physician at the end of the patient’s stay in the hospital. It includes a summary of everything that occurred from admission to discharge, including laboratory data, x-ray data, and pertinent physical findings throughout the hospital course. The report usually ends with the discharge diagnosis and a detailed plan for the patient. If the patient is transferred to another institution (such as a nursing or other hospital), the name of the report is usually changed from discharge summary to transfer summary. If the patient has expired (died) during the hospital stay, the report is usually called a death summary.
History and Physical (H&P)
H&Ps are usually dictated by the admitting physician or resident when a patient is admitted to the hospital. It usually begins with a chief complaint. The “history” includes a history of the present illness, past medical history, social history, and family medical history. Smoking can go under the heading of either Social History or Habits. There is usually a review of systems and a complete physical examination from head to toe. The report usually ends with an admission diagnosis and a plan for the patient treatment.
Operative reports are dictated by the operating physician and contains detailed information regarding an operative procedure. Included in this report are preoperative and postoperative diagnoses, the type of surgery or surgeries that were performed, the names of the surgeon’s and attending nursing staff, the type of anesthesia and the name of the anesthesiologist, and a detailed description of the operative procedure itself. Depending on the operative procedure, information regarding instrument counts, sponge counts and blood loss are also dictated. Often the report will end with disposition or where the patient was transferred when he left the operating room (usually recovery room) and the condition of the patient at the time of transfer.
Radiology reports are dictated by the radiologist upon completion of a diagnostic procedure and includes the radiologist’s findings and impression. Examples of radiology reports are x-rays, CT scans, MRI scans, nuclear medicine procedures and fluoroscopic studies.
Pathology report is dictated by a pathologist and describes findings of a tissue sample. The focus of the report is on the microscopic findings and the pathological diagnosis of the sample.
Lab reports describe findings of examinations of bodily fluids such as blood levels and urinalysis. Laboratory reports are rarely dictated separately but are often included inside the H&P, consultation or discharge summary.
Other miscellaneous hospital reports include cardiac catheterizations, electrophysiology studies, phacoemulsification, autopsies, workmen compensation, insurance assessment, and psychological assessments.
Transcribing medical dictations accurately and affordably is extremely important. We, at ScribeDoctor, support this cause with our decade long service history and professionalism.
Our Process for Types of Medical Transcription Reports:
1. Client uploads dictation to us in secure manner via our Transcription Manager platform. If the client has his/her own platform and specifications, then we follow that.
2. We run the voice files through an internally developed voice recognition engine.
3. A transcriptionist called an MT (a Medical Transcriptionist) proofs the report with voice file word to word.
4. Transcriptionist then reads the report without listening to the voice file and re-listens words or phrases that may require a double check.
5. An editor called a TE (Transcription editor) proofs the word file with voice.
6. The TE reads the report without listening to the voice file and re-listens words or phrases that may require a double check.
7. We upload the text files securely to Transcription Manager for the client to download. If the client has his/her own platform and specifications, then we follow that.
8. Feedback, if any, from the client is taken and studied for improvement.
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Email ([email protected]) us about the problem with an attachment of the file. We will look into it and rectify.
2. What is the cost for medical transcription?
We charge per line. 1 line is 65 characters. We will look into your sample file and mutually agree up on a rate per line. You can be rest assured it will be as per industry standards.
3. Can I record on my phone?
We are afraid it will not have the necessary clarity for us to hear it properly and type it error-free. As this is not an one time task, we request you to use professional recording devices like the Philips speech mike and speak into it clearly and without distraction.
Contact Us for Transcription of any type of medical reports including but not limited to:
|SOAP Note Transcription|
|Consultation Letters Transcription|
|Discharge Summary Transcription|
|History and Physical (H&P) Transcription|
|Operative Report Transcription|
|Radiology Report Transcription|
|Pathology Report Transcription|
|Laboratory Report Transcription|
|Workmen compensation Transcription|
|Insurance assessment Transcription|
|Psychological assessment Transcription|