Examples of Medical Transcription Reports

Approximately 600 million clinical documents are dictated in the United States annually, and 60 percent are transcribed reports. When you see a medical professional, they document your visit by dictating notes that will be transcribed by a medical transcriptionist. The turnaround time and accuracy of these reports is critical to your care. The health-care professional, or facility you visit, will determine the types of medical reports that will be dictated and transcribed.

Basic Four

• At hospitals, the attending physician is responsible for dictating a history and physical. This report describes why you came to the facility and provides a brief personal, family and social history. It gives a detailed report of the findings on physical examination. If an evaluation by a specialist is necessary, the consulting specialist is responsible for dictating a consultation report, which describes his findings. If an operation is done, the surgeon is responsible for dictating an operative report, which describes in detail what is done during surgery. The attending physician must do a discharge summary when a patient is discharged from the hospital. This report summarizes the entire patient visit, all the findings and the plan for treatment after discharge. These four reports are known as the "basic four."

Hospital Reports

• Other reports that may be transcribed in a hospital are radiology reports, pathology reports and laboratory reports. Radiology reports will include basic radiographs, CT scans, PET scans, MRI scans and ultrasound reports. Pathology reports will include cultures, tissue evaluations, and autopsies. Laboratory reports will include results of blood analysis. Additional transcribed reports include summaries from the sleep lab, cardiac catheter lab or other specialized testing areas.

Office Reports

• Reports created in a physician's office are not as regulated as those in the hospital setting. Some private practices still use handwritten notes. Larger physician practices utilize medical transcriptionists, and the notes routinely transcribed include initial evaluations, letters to referring physicians, patient introduction letters to specialists and chart notes for each visit. If a physician orders tests, a note will be made, but the report transcribed by the health-care facility performing the test will be included in the patient's office record.

Reform

• With health-care reform and the focus on patient care, all health-care facilities are being given incentives to convert to an electronic medical record (EMR). The goal is to consolidate all patient records into one repository that can be accessed by health-care professionals treating a patient. This will allow health-care professionals involved in treatment to see the full cycle of care a patient has received. This should result in improved patient care and safety.

Future

• The Health Story Project, formerly The Clinical Document Architecture for Common Document Types, is an alliance of health-care professionals whose main objective is to develop and promote data standards that support the flow of information between transcribed documents and EMRs. They feel that the information in a patient record is underutilized because of its free-form nature, and their goal is to improve consistency of documentation.