 There is no set format for each type of medical document.

Every facility has its own format and design, but any
professional document should be well balanced and
attractive, with single spacing, double spacing between
headings, and 1-inch margins. Being familiar with the logical
sequence and proper sorting of information for each type of
document will help you adapt to any prescribed format.
Headings and subheadings are used to report the
information gathered in the course of a patient encounter.
These general headings are seen in the sample reports in
Figures 9-2 to 9-9.
 1. Prepare the equipment: transcribing machine,
headphones, transcription (dictation) tapes, computer or
typewriter, paper, letterhead, and envelopes.
 2. Select a transcription tape with the oldest date, unless
there are special requests for priority reports.
 3. Turn on the transcriber, and insert and rewind the tape.
 4. Put on the headset and position the foot pedal in a
comfortable location.
 5. Play a sample of the tape. Adjust the volume, speed, and
tone dials to your comfort.
 6. Select the appropriate format and place proper patient
identification on the page.
 7. Play a short segment of the tape by pressing the foot
pedal, stop the tape, and type the message.
 8. If you come across an unfamiliar term, leave enough blank
space for the provider to write it in and continue transcribing.
When you have finished the document, contact the physician
or colleague or use a reference book to fill in the blank.
 9. When you are finished, place the initials of the provider,
followed by a slash and your initials, on the bottom of the
page. The date that each was done should be added.
 10. Spell check the document by using medical spell
check software.
 11. Print and proofread the document.
 12. Leave the document, along with the tape, in a
designated area for review.
 13. After the provider has reviewed and approved
the document, make a copy of the report for the
patient’s chart.
 14. Send the report to the recipient.
 15. Erase the tape and return it to the dictation area.
 Hospital (inpatient) documents and medical office
(outpatient) documents are different. The most common
documents transcribed in a medical office are history and
physical examination (H&P) reports, consultation reports,
and progress notes. Practices that offer diagnostic tests are
required to generate a report of the findings. For example, a
neurologist’s practice may perform electroencephalography
(EEG) to measure the electrical activity in the brain. The
medical assistant transcribes a dictated report of the
findings.
 Other types of documents in outpatient facilities are reports
of minor surgical procedures, legal abstracts, and general
office correspondence.
 Documents that are seen in the hospital setting include
H&Ps, consultation reports, radiology and pathology reports,
transfer summaries, discharge and death summaries, and
autopsies. Many radiologists who work in hospitals also have
a private practice and will dictate a report for each radiology
procedure done in the office. You need to become familiar
with the reports generated in a hospital because they
become a part of the office chart and are used for insurance.
 In the inpatient setting, the H&P is a vital part of the quality of patient care. The
JCAHO (Joint Commission on Accreditation of Health Care Organizations)
accredits and regulates every aspect of the policies and practices of hospitals
 and physician offices owned by hospital organizations. JCAHO guidelines require
hospitals to provide a H&P on a patient’s chart within 24 hours of admission in a
facility.
 This report is dictated by the admitting physician and must be signed or
authenticated electronically within a specified time. Many times the patient is
seen in the office, and the physician makes the decision to admit. The
examination takes place in the office, but the report is dictated to the hospital,
which is responsible for transcription. Many physicians use the H&P format to
record a patient’s annual physical examination in the office as well.
 The H&P is divided into two sections: the history, which gives an overview of the
patient’s medical, family, and social history; and the report on the physical
examination, which reviews the results of the examination.
 When one provider refers a patient to another,
usually a specialist, the consulting physician
prepares a consultation report to report the findings
of the encounter. A consultation report contains a
detailed account of the consulting physician’s
findings and recommendations regarding the
patient. These reports are often written in the
format of the H&P but are structured as a letter to
the physician who referred the patient. Chapter 18
discusses the use of the terms referral and
consultation.
 In the outpatient medical facility, the patient’s progress is recorded on an
ongoing sheet in the chart (see Chapter 8). When the notes are
transcribed, they are printed either directly on this sheet or on special
paper with perforations and adhesive backing. The reports are separated
and stuck on the progress sheet. Remember, the entries in the medical
record must be consecutive. This presents a problem if the transcription
is not on the chart when the next entry is made. Entries that are out of
order give the appearance of disorganization, improper record keeping,
or even an attempt to cover up negligence. Progress notes are formatted
in several ways. These are discussed in Chapter 8. The SOAP (subjective,
objective, assessment, plan) method of reporting a patient’s visit is the
most common format used in medical offices. The report is dictated in
narrative form using general headings. In the outpatient medical facility,
you will transcribe this information.
 Subjective. The subjective portion of the report includes information that cannot be
detected or measured. This information can only be provided by the patient. Pain and
nausea are examples of subjective information. This heading also includes the chief
complaint (CC), the reason the patient is at the facility. In the subjective section, the
provider explains the chief complaint in detail, including how long the symptoms have been
present and what remedies the patient has tried, along with their results. This is sometimes
called the history of present illness (HPI). A subheading titled Medication may be included in
this section to report medications that the patient is taking.
 Objective. The objective information in this section comes from the physical examination,
laboratory data, diagnostic test results, and other data that can be measured or observed.
The patient’s appearance, vital signs, any rash, and results of laboratory tests are examples
of objective information. For example, the narrative report might say, “EEG is normal.”
 Assessment. As discussed earlier, the assessment portion of the report refers to the
established or possible diagnosis based on the subjective and objective information
provided and gathered. Other subheading titles include Diagnosis, Evaluation, Impression,
and Differential Diagnoses.
 Plan. The plan is the steps the physician intends to take.
 They are usually typed in a numbered list. Medications prescribed, diagnostic tests ordered,
referrals to other physicians, and return appointments are included in this section.
 H&Ps, consultation reports, operative reports,
pathology reports, radiology reports, discharge
summaries, and death summaries are generated
primarily in inpatient facilities.
 Every document generated by a hospital
transcription department is “copied to,” that is,
copied and sent to the physician who dictated it.
These documents are kept in the physician’s office
chart.
 Each surgical procedure performed in a hospital is documented.
Physicians dictate an operative note immediately after the procedure. It
is typed and put on the chart as soon as possible so that others caring for
the patient have access to the information. When physicians perform
surgery in their outpatient offices, the operative report is transcribed in
the physician’s office. The terms used in operative reports are often
difficult. Many sutures and instruments are named for the person who
developed them. A reference book for surgical terms is essential for
transcribing. Information included in the operative reports includes the
patient’s preoperative and postoperative diagnoses, the type of
anesthesia used, step-by-step details of the procedure, estimated blood
loss, results of sponge and instrument counts, and the condition of the
patient at the end of the procedure. The subheadings usually follow that
format. Figure 9-5 is a sample operative report.
 Any organ or tissue removed from a patient
in the operating room is examined by a
pathologist. A pathology report outlines the
findings of gross and microscopic
examinations performed on organs, lesions,
and tissue samples removed in surgery.
Figure 9-6 is an example of a typical
pathology report on a specimen.
 Pathologists also dictate autopsy reports. An autopsy report,
also called necropsy report or postmortem examination
report, is generated as the autopsy is performed. Autopsies
are done to find the cause of death of a patient or to find or
confirm diseases present. As discussed in Chapter 2, the law
requires that autopsies be performed in cases of . . . . The
autopsy report includes a preliminary diagnosis, a brief
history of the patient, findings from the examination of the
gross anatomy of the body and its organs, findings of the
microscopic examination of the cells, and a determination of
cause of death.
 Each radiograph must be interpreted by a
radiologist. Even when radiological
procedures are performed in an emergency
room or walk-in clinic, a radiologist must read
the film and dictate a formal report.
Radiology reports include the title of the
procedure, any contrast medium or nuclear
medicine given, and an interpretation of the
film
 The discharge summary is a chronological account of the patient’s
hospital stay. If the patient is being transferred to another facility, this
report may be titled Transfer Summary. It is a concise report of the
reason for the patient’s admission, tests performed, treatments given,
results of those tests and treatments, procedures performed,
improvements, setbacks, and, finally, the condition of the patient at the
time of discharge. The discharge summary is an excellent tool for
members of the health care team involved in the patient’s posthospital
care. A patient who is recovering from a stroke may receive services from
a home health nurse, a physical therapist, and a speech therapist. The
discharge summary provides a snapshot of the patient’s situation in one
document. Be sure it is in the office chart for the patient’s first visit after
hospitalization.