Know the Five Kinds of Medical Transcription Reports

Medical transcription belongs to the periphery of the vast healthcare industry. It could be defined as the process of converting the doctors’ dictations into well-formatted text documents. It helps create the patients’ medical history, which is utilised for reference by healthcare providers and insurance companies, and lays the foundation for future visits. 

Appointing a competent professional can ensure reliable and accurate transcription of the dictated notes. The following write-up specifies five kinds of medical transcription reports that you may request. Please check them out now.

Physical and History Report

The experts offering the best transcription services said this particular report is generally dictated by the physicians when a patient is admitted to a hospital. It begins with the primary complaint, followed by a history of a patient’s current sickness, medical history, family history, and social history. This is regarded as the thorough physical examination end ends with a treatment plan and admission diagnosis.

Operative Report

This report is specified by an operating physician and includes a comprehensive description about the operative procedure. It also has name of the surgeon and anesthesiologist. Based on the procedure, blood loss, count of instruments, etc. are also there. The report ends with a disposition or where the patient was transferred when he/she left the operating room and the entire health disorder of the patient.

Consultation Report

This is dictated by a physician to whom the admitting physician has referred the patients. The consulting physician is generally a specialist in a specific area other than the admitting physician. It also features a brief description about the sickness of the patient and a physical examination dependent on the kind of consultation requested. It also includes laboratory findings and X-rays.

Discharge Summary

This report is stated by the physician at the end of a patient’s stay in the hospital. All important reports starting from the admission of a patient until discharge will be mentioned. The report ends with a thorough plan for a patient. If the report is transferred to another organization, then it changes from a discharge to transfer summary. In case a patient dies, it will be called death summary.

Office Report

Reports that are made in a healthcare practitioner’s office are not considered as hospital reports. Some of them are initial analyses, letters to referring doctors, and introduction letters to experts, and chart notes.

According to the experts providing the best transcription services, error-free medical transcripts contain significant patient information. The doctors rely on these transcripts when deciding which treatment will be best suitable. A minor mistake or misspelt medication or dosage can turn out to be life-threatening.

Accurately transcribing the doctors’ dictations into properly documented reports is necessary for patient safety and optimal healthcare service. Collaborate with the best medical transcription company and get impeccable texts for an affordable price.