There are many different types of reports that medical transcriptionists can type. An employer, medical transcription company/service, or doctor will provide you with a format he/she likes to use. You will see that most physicians/doctors dictate basically the same sections for each report. I have a few doctors that use the same wording for all their reports and it only changes depending on what the patient has. All doctors use a certain format but change it around to their specific likings. Since you will be typing for specific doctors you will get used to how they talk, say words, format their reports, and even be able to know what the doctor was trying to say when they mispronounce a word or if the dictation audio was bad when he was saying a specific word.
Below are the examples of proper grammar usage, punctuation, capitalization, abbreviations, numbers, numerals, and correct spelling for medical terms, and their plurals, and also a list of medical transcription specialties that can be useful.
Propper Grammar Usage - Punctuation, Capitalization, Abbreviations, Numbers, Numerals, And Correct Spelling For Medical Terms And Their Plurals.
Medical Transcription Specialties - List and description of 42 different specialties.
When you see a doctor whether it's an emergency visit, a stay in the hospital, a regular routine checkup, or if you are seeing a specialist for a specific problem, they document your visit by dictating notes that will be transcribed by a medical transcriptionist. A study shows that about 600 million clinical documents are dictated in the United States annually, and 60 percent are actually transcribed reports.
When you go to a hospital, the attending physician is responsible for dictating a history and physical report on that person. This history and physical is basically a two-part medical report which documents the current and past conditions of the patient. It contains both subjective and objective information and forms the basis of most treatment plans. The first half of the report includes subjective information, typically supplied by the patient or their caregiver, about their current medical problems or the reason for the patients visit. This information is followed by a description of any past or ongoing medical issues which include current medications and if they have any allergies to medications. Information is also obtained about the patient's lifestyle, habits, and diseases they have and that of their family members.
The second half of the report contains objective information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures. The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
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.
If an evaluation by a specialist is necessary, the consulting specialist is responsible for dictating a consultation report, which describes his findings on that patient. If an operation is done, the surgeon is responsible for dictating an operative report, which describes in detail what is done during the surgery.
There can be many reports done on one patient. No matter where the patient goes to get evaluated, reevaluated, a follow-up visit, surgery, or just a consultation a report is done dictating everything on that patient and the reason why that patient came to their office.
When you are typing a report and get stuck on a word that you do not understand or the doctor mumbled that word, don't get frustrated and don't spend too much time trying to figure it out. Highlight the word so that you can come back to it. Most likely the doctor will repeat that word again later on in the dictation and then you can go back and type it correctly. This has happened to me many times and I have learned not to waste my time trying to figure out what that word is.