| What are the types of reports that need to be | | | | postoperative details. |
| transcribed? | | | | - Radiology report: This contains details of the |
| A patient-provider interaction typically happens when a | | | | radiologists' findings on the X-rays, MRI scan, Ct scan, |
| patient visits a doctor or healthcare provider for: | | | | nuclear medicine, fluoroscopic studies etc along with |
| - Regular health checks | | | | the reports. |
| - Specific health issue | | | | - Pathology report: This contains the findings of a |
| - Emergency care | | | | pathologist of the tissue sample. |
| - Specialist referral | | | | - Laboratory report: This contains the laboratory |
| - Procedure | | | | findings on body fluids |
| - Surgery/ Diagnostic test | | | | - Emergency report: This is a summary of the patient's |
| Once the patient-doctor encounter ends detailed | | | | visit to the emergency room for emergency care. |
| records need to be created of the whole process. | | | | - SOAP note report: This contains |
| This is not only a statutory requirement, but also aids | | | | - Subjective: This section contains patient's current |
| the doctor in the treatment process, checking on the | | | | condition like age, gender, and pertinent symptoms etc. |
| progress of the patient, providing proof in case of | | | | - Objective: This section contains vital signs, findings |
| litigation and also used further for billing and | | | | from physical exams. Lab test results, co morbidity etc. |
| reimbursement. Medical transcription plays an important | | | | - Assessment: This contains quick summary of |
| part in the process of record creation. | | | | symptoms and diagnosis etc. |
| The types of reports that are created by medical | | | | - Plan: This contains treatment plans, document goals |
| transcriptionists are as follows | | | | for the patient with reasonable time lines etc. |
| - Patient History and physical examination report: This | | | | - Progress note report: This contains progress of the |
| contains a brief about the patient name, age, gender, | | | | patient after treatment/ operation/ procedure etc. |
| occupation, family health history, habits like smoking etc. | | | | - Therapy report: This contains details of the therapy |
| and the details of the physical examination. | | | | given to the patient |
| - Consultation report: This contains the details of the | | | | - Discharge summary: This contains all the details |
| findings by the consultant to whom the patient has | | | | which are generated when the patient is discharged |
| been referred to for further treatment or diagnosis | | | | including the treatment given, the progress of the |
| depending on the symptoms | | | | patient, any reports and findings etc. |
| - Operative report: This contains the details of the | | | | In light of the vital information that comes out of each |
| operation/surgery that a patient has undergone | | | | patient encounter with a healthcare facility, medical |
| including details of the procedure, duration, the | | | | transcription is an important component in the |
| anesthesia given etc. This may also contains some | | | | healthcare delivery cycle. |