Medical transcription is a process that functions at the periphery of the healthcare industry. It is the process of converting dictations of the healthcare professionals into well-formatted text documents. It plays a vital role in creating the patient’s medical history which is used for reference by healthcare providers, medical practices, insurance companies, and lays a foundation for future patient visits. Choosing the right professional medical transcription service is important to ensure accurate and reliable transcription of your dictated notes.
There are different types of medical transcription reports that you can request.
- History and Physical report: This report is usually dictated by physicians when a patient is admitted to the hospital. It starts with the main complaint, followed by history of the patient’s current illness, medical history, social history and family medical history. This is regarded as the complete physical examination of the patient and ends with an admission diagnosis and a plan of treatment.
- Consultation report: This is dictated by the physician to whom the admitting physician has referred the patient. The consulting physician is usually a specialist in an area other than the admitting physician. It also includes a small description about the illness of the patient and a specific physical exam based on the type of consultation requested. It may also include x-ray or laboratory findings. This report concludes with the physician’s impression and treatment plan.
- Operative report: This report is dictated by the operating physician, which includes a detailed description about operative procedure. Details include pre-operative and post-operative notes, the type of surgery, name of the surgeon, anesthesiologist, and a detailed description of the operative procedure itself. Based on the type of surgery, the count of instruments, blood loss etc are also mentioned. The report will end with disposition or where the patient was transferred when she left the operating room and the overall health condition of the patient.
- Radiology report: This report is dictated by the radiologist once the diagnosis and radiology procedures are completed. It includes the radiologist’s findings and interpretations of x-rays, CT scans, MRI scans, nuclear medicine procedures and so on.
- Pathology report: This report is dictated by the pathologist and includes the microscopic findings of the sample.
- Laboratory report: This report includes the findings of examinations of bodily fluids such as blood levels and urinalysis. This report is rarely dictated separately but often included in the H&P, consultation or discharge summary.
- Hospital report: This will include all the reports that were dictated in the hospital – radiology reports, pathology reports and laboratory reports.
- Discharge summary: This report is dictated by the physician at the end of the patient’s stay at the hospital. All crucial reports right from the admission of the patient until discharge will be included. The report ends with a detailed plan for the patient. If this report is transferred to another institution, then it changes from discharge summary to transfer summary. If the patient dies, then it will be called death summary.
- Office reports: Reports that are created in a medical practitioner’s office not treated as hospital reports. Some of these are initial evaluations, letters to referring physicians, patient introduction letters to specialists, and chart notes for each visit.
Accurate medical transcripts contain important medical data of patients for future reference. Doctors go through these medical transcripts and charts to review patient evaluations and decide which treatment is best suitable. A minor error in the transcript or a misspelling of medicine or dosage can cause major health issues or even lead to death. Therefore, accurately transcribing doctors’ dictation into well-documented reports is essential to ensure patient safety and better healthcare service. Partnering with a reliable medical transcription company helps in transcribing audio files with utmost accuracy at affordable rates.