Medical Transcriptionist’s
Role With Medical Report Formats And Style
Submitted By: Connie Limon Medical report formats and styles vary according
to your location. The examination portion of a routine History and Physical
report might be transcribed in block paragraph form or with indentations,
hanging paragraphs, with subheadings in all capitals, or subheadings in
upper and lowercase letters. There is no real set in stone format or style.
You will need to follow the instructions of your employer about report
formats and styles.
Sometimes the physician’s dictating style determines the appropriate
format, or the medical facility you work for may mandate certain formats
as standard.The medical transcriptionist is usually allowed to add headings
and subheadings to a dictated report as appropriate. While transcribing,
the medical transcriptionist needs to be alert for when to insert an appropriate
heading that is not dictated but is vital to the report.
An example of this might be the dictator does not dictate such headings
as “Diagnosis,” or “Final Diagnosis,” or “Discharge
Summary.” The Medical Transcriptionist should insert these types
of headings when the dictator fails to dictate them.If you find yourself
inserting appropriate headings not dictated by the dictator, you will
need to flag the report to the attention of the dictator so that the diagnosis
or final diagnosis can be stated if the information is left out. Of course,
if only the heading is left out, you would not need to flag the report.If
you come across a dictator that uses abbreviations for report headings
such as CC for Chief Complaint or HPI for History of Present Illness,
always spell these headings out in full as you transcribe.It is not uncommon
for a physician to finish dictating the Physical Examination Click
here for the rest.
