MEDICAL REPORT BASICS

Key components for writing comprehensive medical reports:
 
Dictate the identifying parts of the report. These may include:
 
  • Patient’s Last Name
  • Patient’s First Name
  • Patient’s Date of Birth
  • Date of Visit
  • Health Insurance Number
  • Hospital Number, if applicable
1. Begin the body of the letter by describing the reason for referral as an introductory sentence, e.g: “The patient is a  32-year old diabetic referred for shortness of breath.”
 
2. Describe the patient’s history by using several topics such as
 
  •  History of present illness
  •  Past medical history
  • Current medications
  • Allergies
  • Family history
  • Social histor
  • Review of Systems: Under Review of Systems list further details of the body’s systems (e.g.: head, eyes, ears, nose and throat, respiratory, cardiac, gastrointestinal, endocrine) along with any pertinent symptoms the patient is  experiencing for each system.y
 
3. Physical Examination
 
Describe the patient’s exam. Subheadings in this section can include, “General Appearance,” “Head, Eyes, Ears, Nose, and Throat,” “Neck,” “Lungs,” “Heart,” “Abdomen,” “Extremities,” “Skin,” “Neurologic” and any others that may be pertinent. The subheading pertaining to your specialty will likely be more detailed than the others.
 
Qualified Text: If you use certain standard phrases that are always the same for e.g. normal cardiac results, fully dictate the detailed text during the first dictation. Later you would dictate only an instruction such as “insert normal text” and the transcriptionist will type the entire paragraph that is required for ‘normal patients’. This will save dictation and transcription time.
 
4. Diagnostic/Laboratory Studies
 
Include any results of pertinent laboratory tests that are available for review, by stating the test values and whether the results are within normal limits. This may also be results of any imaging already done, such as X rays or magnetic resonance imaging.
 
5. Assessment/Impression
 
In this section of the report the specialist expresses his/her professional opinion of the patient’s condition based on the history, physical exam and lab studies. While your professional opinion will be relative to your specialty, there may also be consideration for other conditions the patient may have. Depending on the case you may describe a likely diagnosis or several possible diagnoses. For example, a consulting allergist may need to consider whether a patient’s skin rash is not caused by a food allergy but by an underlying skin condition.
 
6. Recommendations
 
Explain the steps needed to address the patient’s condition. In the example in item 6. Above, the allergist may recommend that the referring physician orders food sensitivity testing or he/she may suggest a further referral to a dermatologist. This section will also indicate whether any follow-up appointments are needed with you.
 
7. Closing
 
Conclude the report with a sentence thanking the referring physician for involving you in the patient’s care. If needed, also provide your contact information.


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