Types of Reports the MT Learns to Transcribe

 

 

There are a number of medical related reports generated each day in doctorís offices, clinics and hospital settings. The professional MT needs to be familiar with all reports and documentation dictated in each type of work environment.

Private practice physicians frequently dictate office chart notes, correspondence, new patient office evaluations as well as the patientís history and physical examinations.

The medical reports dictated in medical centers and hospitals are quite varied in category; however, generally include dictations comprised of four basic reports including: Patientís history and physical examination; a Consultation Report; Operative Report; and Discharge Summary. Other reports include: Emergency Department Reports; Diagnostic Studies; and Hospital Progress Notes.

Healthcare Record:

The patientís healthcare record is a chronological, documented reporting of a patientís initial evaluation, including identified needs, objectives of the patientís care, a prescribed treatment plan, and results of the treatment. The record may be a paper accounting, digitally stored, or a combination of digital and paper documentation.

The healthcare record is the personal property of the hospital or healthcare provider where it originated and cannot be removed from the premises since it is considered a legal record or document. The only way this record may be attained is by subpoena or court order. The record is maintained in the providerís or hospitalís Health Information Department usually supervised by an RRA or registered record administrator; an ART or accredited record technician, or an individual possessing an MBA or masters of business administration.


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