Medical reports are a way to communicate between doctors and other health care workers. Due to the notably sensitive nature of this subject, there is no place for errors in these reports. So, to maintain an updated record, the health care providers send medical reports for transcription.
Transcriptionists need to know the types of reports to present the correct data in the written form. Therefore, today we will discuss in detail the five major types of medical reports for transcription.
Consultation Reports
A consultation report is one step ahead of the primary physician’s findings. In these reports, consultants direct the details of the illness and their views about it. In addition to it, it comprises of the treatment plans and physical tests such as X-ray findings. These reports vary in length as per the type of illness. Also, on the extent of the state. So, the charges for medical reports for transcription also vary.
History and Physical Reports
These two types of reports are commonly known as H&P reports, and they are the first point of a patient’s scan. History and Physical reports tell why the patient needs medical care.
The history is called the chief complaint that the patient has been facing over time, which includes other medical, family, and social history.
The physical study follows the history report, which adds objective and subjective tests of the sufferer’s body. Finally, H&P tests end with a diagnosis and a therapy plan.
Operative Report
Operative reports include all the details of the working process as told by the surgeon, as it was for the minor details. Since experts note them right after surgery, such reports play a major role in the future. In any case of mishap that happens years after or a trial where the medical board wants to stand with defending arguments, such reports work as a supporting document. It may have these information:
- The names of the surgeons and their assistants
- Pre and post-surgery details
- The process with each detail
- Suspected blood loss
- Findings and specimen removed
- The room where the staff took the patient after the surgery.
Such medical reports for transcription need extra duty and time.
Radiology Report
A radiology report covers two parts. First, the radiologists classify and render test findings and then show them to the doctors. These diagnostic imaging studies or tests include x-rays, MRI, CT scans, etc. Then, as per the researchers, these are exact reports. For these, the surer the radiologist is in the findings, the shorter the report is.
Discharge Summary
A discharge summary reports the patient’s overall stay in the hospital. The healthcare provider hands over this report to the patient at the discharge.
It helps the next doctor know why the patient was admitted before. Also, what sort of therapy they were getting for their illness.
The Discharge summary has these majors:
- Reason for admitting
- First findings
- Primary diagnoses
- Procedures and treatment given
- Discharge health of the patient
- Discharge advice and post-discharge care
- Doctor’s sign.
Final Take on Medical Reports For Transcription
Despite the healthcare industry you belong to, you need such reports to process the treatments.
So, you can see there are problems in writing medical reports, and it needs accuracy, which one cannot settle. Therefore, only expert transcriptionists must make a copy of any report.
Further, transcription services in Canada are vital for the hospital sector as there is a strict rule to retain a medical record for insurance companies and further medical usage. So, choose your transcription partner wisely!
