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MT PROPER

Understanding Medical Records

Types of Medical Reports


1. History and Physical Examination Report (H & P)
2. Radiology Report
3. Operative Report
4. Pathology Report
5. Request for Consultation
6. Discharge Summary
7. Death Summary
8. Autopsy Report
9. Outpatient Model Report

History and Physical Examination


- Often called the “H&P” is the starting point of the patient’s “story” as to
why they sought medical attention or are now receiving medical attention.

Common Physical Exam Procedures


• Obvious lesions
• Palpable mass(es)
• Ulceration
• Size (in centimeters or inches) and location (especially if tumors crosses
midline) of primary tumors(s)
• Swelling or enlargement of any masses or organs (organomegaly,
hepatomegaly, splenomegaly, hepatosplenomegaly/HSM)
• Fixation of mass
• Invasion/erosion of bone
• Laterality Side Note:
• Size and number of palpable lymph nodes PRIORITY REPORT
• Especially cervical - Gives overview of
• Supraclavicular the patient
• Axillary or inguinal - Must be
accomplished within
• Evaluation of cranial nerves
24 hours
• Evidence of “frozen” pelvis

HISTORY AND PHYSICAL EXAMINATION TEMPLATE


Patient Name: MEDICATIONS:
Hospital No.: SOCIAL HISTORY:
Room No.: FAMILY HISTORY:
Date of Admission: REVIEW OF SYSTEMS:
Admitting Physician:
Admitting Diagnosis: PHYSICAL EXAMINATION: (consist
of the
CHIEF COMPLAINT: following: Vital signs, HEENT, Neck,
Chest, Cardiac,
Abdomen, RLQ, Rectal, Extremities,
Neurologic)
HISTORY OF PRESENT ILLNESS: DIAGNOSITC DATA:

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Four spaces between
last
Paragraph and signature
rule
Name of Doctor
Double space from
signature block to
SB:xx dictator/ transcriptionist
initials
D: 12/01/2009
Format dates as
MM/DD/YYYY
T: 12/01/2009

CC:

RADIOLOGY REPORT

- The radiology report is a description of the findings and the interpretation


of radiographs and other studies done by a radiologist.

RADIOLOGY REPORT

Patient Name:
Hospital No.:
X-ray No.:
Admitting Physician:
Procedure:
Date:

PRIMARY DIAGNOSIS

CLINICAL INFORMATION

IMPRESSION

Side Note:
Roentgenography – making
records of the internal
structure of the body.

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OPERATIVE REPORT

Patient Name:
Hospital No.:
Date of Surgery:
Admitting Physician:
Surgeons:
Preoperative Diagnosis:
Postoperative Diagnosis:
Operative Procedure:
Anesthesia:

DESCRIPTION:

PATHOLOGY REPORT

Patient Name:
Hospital No.:
Pathology Report No.:
Admitting Physician:
Preoperative Diagnosis:
Postoperative Diagnosis:
Specimen Submitted:
Date Received:
Date Reported:

GROSS DESCRIPTION:
GROSS DIAGNOSIS:
MICROSCOPIC DIAGNOSIS:

REQUEST FOR CONSULTATION

Patient Name:
Hospital No.:
Consultant:
Requesting Physician:
Date:
Reason for Consultation:
BURNING AGENT: *Example

TREATMENT PLAN

GOALS

REQUEST FOR CONSULTATION

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DISCHARGE SUMMARY (Final Progress Note or
Clinical Resume)

Patient Name:
Hospital No.:
Admitted:
Discharged:
Consultations:
Procedures:
Complications:
Admitting Diagnosis:
HISTORY:
DIAGNOSTIC DATA ON ADMISSION:
HOSPITAL COURSE:

DISCHARGE SUMMARY:

DEATH SUMMARY

Patient Name:
Hospital No.:
Admitted:
Deceased:
Consultations:
Procedures:

ADMITTING DIAGNOSES
FINAL DIAGNOSES

COURSE IN HOSPITAL:
DIAGNOSTIC DATA:
CAUSE OF DEATH

HISTORY, PHYSICAL, IMPRESSION, PLAN

Patient Name:
PCP:

Date of Birth:
Sex:

Date of Exam:

HISTORY:
PHYSICAL EXAMINATION: (HEENT, NECK, CHEST, SKIN,
ABDOMEN, EXTREMETIES)
IMPRESSION:
PLAN:

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AUTOPSY REPORT

Patient Name:
Hospital No.:
Necropsy No.:
Admitting Physician:
Pathologist:
Date of Death:
Date of Autopsy:
Admitting Diagnosis:
Prosector:

FINAL ANATOMIC DIAGNOSES


PERITONEAL CAVITY:
MEDIASTINUM AND THYMUS:
PLEURAL CAVITIES:
PERICARDIAL CAVITY:
HEART:
GREAT VESSELS:
THYROID:
PARATHYROIDS:
LARYNX AND TRACHEA:
LUNGS AND BRONCHI:
GASTROINTESTINAL TRACT:
LIVER:
GALLBLADDER:
PANCREAS:
SPLEEN:
ADRENALS:
KIDNEYS:
URETERS AND BLADDER:
GENITAL ORGANS:
LYMPH NODES:
BONES AND JOINTS:
BONE MARROW:
CRANIAL CAVITY:
BRAIN:

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SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN

Patient Name: PCP:

Date of Birth: Age: Sex:

Date of Exam:

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLAN

CORRESPONDENCE/LETTER

Address and Telephone No. of the Hospital or Clinic

Date

Name and Address of the Doctor

Re: Patient Name


Date of Birth

Dear Dr. ---:

BODY of the LETTER

Sincerely,

Name of the Doctor


Specialization

SCG: xx

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