| There are a variety of medical reports created | | | | treatmento May also include laboratory tests |
| every day in physician offices, clinics, and hospitals. | | | | results |
| A Medical Transcriptionist needs to be familiar with | | | | Doctors use numerous formats for dictated chart |
| the medical reports dictated in each work setting. | | | | notes. The SOAP format is common. SOAP |
| Types of reports dictated in private physician | | | | stands for the headings of:o Subjectiveo |
| practice include:o Office chart noteso Letterso | | | | Objectiveo Assessmento Plan |
| Initial office evaluationso History and physical | | | | Physicians frequently dictate letters to |
| examinations | | | | communicate patient information to other |
| Types of reports dictated in hospitals and medical | | | | physicians, insurance companies, and government |
| centers are numerous. The reports include | | | | offices. A Medical Transcriptionist will need to be |
| dictations from a basic four which are:o History | | | | familiar with the various standard business letter |
| and Physical Examinationso Consultation Reportso | | | | formats. Employers sometimes express a |
| Operative Reportso Discharge Summaries | | | | preference for a specific letter format. Most |
| In addition to the above reports emergency | | | | commonly used is the full-block format with the |
| department reports, hospital progress notes and | | | | parts of the letter lined up on the left margin. |
| diagnostic studies are often also dictated. | | | | The initial office evaluation is dictated after the |
| The chart note is also called progress note or | | | | physician sees a patient for the first time and |
| follow-up note is dictated by the physician after | | | | contains about the same information as the |
| talking with, meeting with, or examining a patient | | | | history and physical examination. However, a |
| usually in an outpatient setting. Progress notes or | | | | physical examination report in an initial office |
| chart notes are also commonly dictated on | | | | evaluation may be limited to specific areas of |
| hospital inpatients. | | | | disease. |
| The chart note varies in length from one | | | | Continued in Part II |
| sentence to one or more pages and contains:o A | | | | This article is FREE to publish with the resource |
| concise description of the patient's presenting | | | | box. |
| problemo Physical findingso Physician's plan of | | | | |