Types of medical transcription reports

What are the types of reports that need to be transcribed?

Apatient-provider interaction typically happens when a patient visits a doctor or healthcare provider for:

• Regular health checks
• Specific health issue
• Emergency care
• Specialist referral
• Procedure
• Surgery/ Diagnostic test

Once the patient-doctor encounter ends detailed records need to be created of the whole process. This is not only a statutory requirement, but also aids the doctor in the treatment process, checking on the progress of the patient, providing proof in case of litigation and also used further for billing and reimbursement. Medical transcription plays an important part in the process of record creation.

The types of reports that are created by medical transcriptionists are as follows

Ø Patient History and physical examination report: This contains a brief about the patient name, age, gender, occupation, family health history, habits like smoking etc. and the details of the physical examination

Ø Consultation report: This contains the details of the findings by the consultant to whom the patient has been referred to for further treatment or diagnosis depending on the symptoms

Ø Operative report: This contains the details of the operation/surgery that a patient has undergone including details of the procedure, duration, the anesthesia given etc. This may also contains some postoperative details

Ø Radiology report: This contains details of the radiologists’ findings on the X-rays, MRI scan, Ct scan, nuclear medicine, fluoroscopic studies etc along with the reports

Ø Pathology report: This contains the findings of a pathologist of the tissue sample

Ø Laboratory report: This contains the laboratory findings on body fluids

Ø Emergency report: This is a summary of the patient’s visit to the emergency room for emergency care.
Ø SOAP note report: This contains

q Subjective: This section contains patient’s current condition like age, gender, and pertinent symptoms etc

q Objective: This section contains vital signs, findings from physical exams. Lab test results, co morbidity etc

q Assessment: This contains quick summary of symptoms and diagnosis etc

q Plan: This contains treatment plans, document goals for the patient with reasonable time lines etc.

Ø Progress note report: This contains progress of the patient after treatment/ operation/ procedure if any

Ø Therapy report: This contains details of the therapy given to the patient

Ø Discharge summary: This contains all the details which are generated when the patient is discharged including the treatment given, the progress of the patient, any reports and findings etc.

In light of the vital information that comes out of each patient encounter with a healthcare facility, medical transcription is an important component in the healthcare delivery cycle.

One needs to focus on a medical transcription service provider not just for creation of physical records but based on the following criteria:

• Accuracy of above 99%
• Turnaround time of 24 hours
• Reasonably priced
• Secure channels for data transmission

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time and executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

TransDyne's medical transcription service is proven and the team has vast experience in:

• Family Practice transcription
• Internal Medicine transcription
• Orthopedics transcription
• Cardiology transcription
• Neurology transcription
• Psychiatry transcription
• Radiology transcription
• Rehab Medicine transcription
• Pediatrics transcription
• Podiatry transcription
• Physical Therapy transcription
• Ophthalmology transcription
• Hematology & Oncology transcription
• ENT transcription
• Plastic Surgery transcription
• ER transcription
• Ob/Gyn transcription
• Nephrology transcription
• Urology transcription
• Gastroenterology transcription
• General Surgery transcription

To avail expert medical transcription services from TransDyne’s. click here.