OA105 – INTEGRATED SOFTWARE (SPREADSHEET)

SY 2021 – 2022, SECOND SEMESTER

LESSON # 1.
Principle of Medical Transcription

As pharmacist continue to increase their involvement in patient care activities, their ability to
navigate the often murky waters of the medical record becomes even more crucial. Locating
vital pieces of information is critical to developing an appropriate assessment and plan for the
individual patient. Additionally, collecting this data in a systematic way will permit the
pharmacist to then synthesize it and create a comprehensive list of healthcare needs and
considerations for the patient, regardless of the practice setting.

Medical Transcription
Medical transcription, also known as MT, is an allied health profession dealing with the process
of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other
healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or
other spoken material. These are dictated over the phone or uploaded digitally via the Internet
or through smart phone apps.

Medical Records and Management

Purpose:
 Provide base for managing patient care
 Provide interoffice and intraoffice communication as necessary
 Determine any patterns that surface to signal provider of patient needs
 Serve as basis for legal information to protect providers, staff, patients
 Provide clinical data for research

Ownership of a Medical Records

 Property of those who create record
 Information belongs to patient and is protected with privacy and confidentiality
 Patients are allowed access to their medical records and can ask certain information be
added or excluded from their file
 Providers who include their patients in their medical record keeping foster trust and respect
with their patients

Authorization to Release Information

 Before information released from medical record, patient notified and written approval
received
 Identify reason for release and what information specifically requested
 Only that information released
 Does not include release of information to patient’s chosen insurance carrier

The Importance of an Accurate Medical Records

 Accuracy essential to patient care
 Critical to facility’s smooth functioning
 Important when referring patient to outside specialists

Prepared by: PRECYLYN G. BUÑAO, MM | Page 1

 OA105 – INTEGRATED SOFTWARE (SPREADSHEET)
SY 2021 – 2022, SECOND SEMESTER

 Essential in controlling costs

 May be needed in medical litigation

Problem-oriented medical records (POMRs)

S: Subjective impressions
O: Objective clinical evidence
A: Assessment or diagnosis
P: Plans for further studies, treatment, management
E: Education for patient
R: Response of patient to education and care given

Components of a Patient’s Medical Record

The medical record can be dissected into five primary components, including the medical history
(often known as the history and physical, or H&P)
 Laboratory
 diagnostic test results
 problem list
 clinical notes
 treatment notes

Components of a Patient’s Medical Record

Medical History (also known as history and
physical, or H&P)
 Patient demographics
 Chief Complaint (CC)
 History of present illness (HPI)
 Past Medical History (PMH)
 Family History (FH)
 Social History (SH)
 Allergies
 Medication History
 Review of System (ROS)
 Physical Examination
Laboratory Test Results
Diagnostic Test Results
Problem List
Clinical Notes
 Progress Notes
 Consultation Notes
 Off-service notes/transfer notes
 Discharge summary
Treatment Notes
 Medication Order
 Surgical procedure documentation
 Radiation treatments
 Notes from ancillary practitioners

Prepared by: PRECYLYN G. BUÑAO, MM | Page 2

 OA105 – INTEGRATED SOFTWARE (SPREADSHEET)
SY 2021 – 2022, SECOND SEMESTER

Basic Rules for Filing

 Alphabetizing
 Numeric Filing
 Indexing
 Color coding
*segregate inactive and active files

Filing Procedures Filing chart data Types of reports Clinical notes

 Correspondence
 Laboratory reports
 Miscellaneous

Prepared by: PRECYLYN G. BUÑAO, MM | Page 3