Medical Transcription Chapters 5-6

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Types of medical reports and formats Medical office charting and correspondence

It is necessary for medical records to be _______

Uniform

admitting privileges

...

Assessment

Part of the H&P report;
•Admitting diagnosis
Also called the impression, formal assessment of the patient's condition

auditory or aural evaluation

what is heardcapable of being demonstrated to the physician or others

Consultation Report (CONS)

...

current reports

...

Description of the Surgical Procedure

...

Diagnostic Examination

...

Diagnostic Impression

...

Discharge Summary (DS)

•Dictate at the conclusion of the hospital stay
•Summation of what transpired during the patient's hospital admission
•What the outcome or potential outcome of the hospitalization was or may be

Final Diagnosis

The name or names of the specific disease, syndrome or condition that ultimately led to the patient's hospitalization.

Findings

characteristics of the disease (often called signs)

Format

•The arrangement of the proper shape, structure and general form of a particular document.
•Should the document be double-spaced and typed in paragraph form?
•Should it be styled like a letter?

Free-form paragraph format

...

Gross Findings

...

History

One of the two sections of the H&P report.

History and Physical Report (H&P)

•One of the two most basic hospital reports
•Dictated at the beginning of a patient's hospital admission
•Is the documentation of the initial evaluation of the patient's symptoms and physical disorders
•Summarization of the patient's condition and a plan for what should occur during the course of the hospitalization
•Generated by the admitting physician, the resident or hospital internist upon formal admission of an inpatient
•Report is broken down into two sections: the history and the physical

History of the Present Illness (HPI)

...

Hospital Course

Part of the discharge summary report; description of what transpired while the patient was in the hospital.

Inpatient

Patient is admitted to the hospital for at least 24 hours to receive extended medical care

Medical staffing department

...

Microscopic Findings

...

Objective

Capable of being demonstrated to the physician or others

Olfactory evaluation

what is sensed by the nose

Operative Note or Report (OP)

Describes an operation or surgical procedure, both manual (using the physician's hands), and operative (using surgical tools or instruments) for the purpose of correcting, repairing and diagnosing medical abnormalities, defects or diseases. Report is usually dictated by the surgeon or by an assistant.

Outpatient

Patient receives diagnostic evaluation and/or treatment from a particular department of a hospital without staying a 24-hour period.

Paragraph format

...

Past medical history (PMH)

...

Pathological Diagnosis

...

Pathology Report (PATH)

•One of the basic six reports
•This is dictated from the pathology department

Physical

•Height and weight
•Heart sounds
•Skin condition, nodules felt, reflex strength

Physical Examination (PE)

•part of the H&P report
•focuses on the characteristics of the illness that are objective, (or capable of being demonstrated to the physician or others)

Plan

•or treatment plan
•assessment or admitting diagnosis provides a plan of action for the hospitalization

Preoperative and Postoperative Diagnoses

...

Radiology Report (RAD)

•One of the basic six reports
•This is dictated from the radiology department

Recommendations

...

Review of Systems (ROS)

•Part of the H&P report
•Subjective
•Historical review of the patient's complaints specific to each body system
•The physician asks about each body system, and the patient responds as to whether or not he or she has had problems associated with that system in the past
•Patient tells physician about their symptoms, the sensory perception of the illness
•The end of this report is the crossroad of the H&P report

Sensory

•Part of the review of systems
•Characteristics of the illness perceived by the patient through sight, sound, smell, taste or touch

Separate line heading format

...

Stat reports

Such as radiology reports and pathology reports, usually have a turnaround time of 12 hours or less, as the report is probably required for other evaluation and treatment to be performed on the patient.

Subjective

The History part of the H&P report is considered subjective; Relates to the patient's own sense or awareness of his or her condition and the circumstances surrounding it, factors which may or may not be able to be demonstrated.

Operative report

Describes an operation or surgical procedure - a procedure both manual (using a physician's hands) and operative (using surgical tools or instruments) for the purpose of correcting, repairing, and diagnosing medical abnormalities, defects or diseases.
-ususally dictated by the surgeon or by the assistant
Main seciton of the OP is description of surgical procedure, sometimes called the procedure
-Usually also dictated in the report are the diagnoses before and after the operation - called the preoperative and postoperative diagnoses
-the name of the surgeon, title and date of procedure, the indications for surgery, and surgical findings (upon procedure being performed)
-Includes a sponge count
-Estimation of blood lost during the surgery
=Ends when the patient is taken to the recovery room, and physician will usually state the condition of the patient upon leaving the operating room

Symptoms

On the history and physical report

Tactile evaluation

what is felt

The basic four

•History and Physical Report (H&P)
•Discharge Summary (DS)
•Operative Note or Report (OP)
•Consultation Report (CONS)
•These reports form the basis of the majority of all hospital dictation.

The basic six

•History and Physical Report (H&P)
•Discharge Summary (DS)
•Operative Note or Report (OP)
•Consultation Report (CONS)
The above "basic four" are combined with the below two to form the "basic six"
•Pathology Reports (PATH)
•Radiology Reports (RAD)

Turnaround time

The time it takes for the report to be dictated, transcribed and signed or verified by the physician.

Visual evaluation

Part of a physical examination; what is seen

Explain the difference between hospital inpatients and outpatients

a. An inpatient is a patient who is admitted to the hospital for at least 24 hours to receive extended medical care
b. An outpatient is a patient who receives diagnostic evaluation and/or treatment from a particular department of a hospital without

Compare the "basic four" to the "basic six."

The basic four reports form the basis of the majority of all hospital dictation, and include the following:
a. History and Physical Report (H&P)
b. Discharge Summary (DS)
c. Operative Note or Report (OP)
d. Consultation Report (CONS)
The basic six reports are combined with the previously listed "basic four," and combine to make six reports. The additional two reports are as follows:
a. Pathology Reports (PATH)
b. Radiology Reports (RAD)

List the four methods of physical examination evaluation performed by the physician or health professional.

a. Visual exam
b. Olfactory evaluation
c. Auditory or aural
d. Tactile

Who dictates the consultation report, and who receives the report?

The consultation report is requested from a specialist physician by the patient's primary or attending physician. The patient's attending physician requests a consultation for a second opinion. This report is dictated by the consultant and then addressed to (sent to) the attending physician.

Explain the focus of the pathology report

The Pathology (PATH) report describes the pathological, or disease-related, findings of a sample tissue taken. The tissue samples can be taken during surgery, a biopsy, a special procedure, or an autopsy. The pathology report is dictated by the pathologist. The PATH report is a separate report describing specific disease findings and is usually limited to tissue.

List three types of radiology diagnostic procedures

Roentgenograms (basic x-rays)
CT Scans (computerized tomography scans)
MRI scans (magnetic resonance imaging scan)

List six section headings contained in the dismissal summary:

a. History of present illness
b. Past history
c. Social history
d. Family history
e. Physical exam
f. Laboratory data

What are "aged" reports, and what are the turnaround time parameters for these reports?

Aged reports are discharge summaries and emergency room notes. These are usually not required in the patient's file before other measures can be taken in terms of his or her treatment, thus turnaround time on these reports is usually 72 hours.

Which reports are almost always dictated by someone other than the attending physician?

a. The consultation report
b. The pathology report (dictated by the pathologist)
c. The Radiology Report (dictated by the radiologist)

Explain how the separate line heading format differs from the freeform paragraph format.

If information is dictated freeform, meaning without section headings, it is sometimes easier to do this in paragraph form. Separate line-heading formats are broken down into sections; and as a rule, use the separate line-heading format unless directed otherwise in H&P report, and the free-form paragraph format for discharge summaries.

FLUOROSCOPIC CATHETERIZATION

Radiology Report

SPONGE COUNT

Operative Note

RECOMMENDATIONS

Consultation Report

FOLLOW-UP

Discharge Summary

TISSUE SUBMITTED

Pathology

CHIEF COMPLAINT

History and Physical Report

FIRST ASSISTANT

Operative Note

Because of the voluminous amount of documentation associated with patient hospital visits and stays, the majority of medical records have historically been produced in _________.

Hospitals

The majority of formats with which a medical transcriptionist must be familiar are used in the transcription of _______ ________.

hospital dictation

Each medical report has a ______ ______ specifically tailored to make it concise, clear, and uniform

unique format

Those who dictate usually follow a very general format for whatever report they are dictating, although every report varies slightly in ______ and _____.

content; form

Most medical reports are broken down into various ________, and those have __________.

sections; subsections

Sections have titles called ______, and the subsections have titles called __________.

headings; subheadings

The report sections are only _________ the dictator may or may not choose to follow when dictating a medical report.

guidelines

The two most basic hospital reports are called:

•History and Physical Report (H&P)
•Discharge Summary (DS)

The History portion of the History and Physical report is:

A summary of the chronological record of situations, events, and other associated topics that may have contributed to the patient's admission into the hospital.
This portion of the report is sometimes called "subjective"

Why is the history portion of the H&P report called subjective?

Because it relates to the patient's own sense or awareness of his or her condition and the circumstances surrounding it, factors which may or may not be able to be demonstrated.

The main sections of the history section part of the H&P report are entitled:

•History of the Present Illness (HPI)
•Review of Systems (ROS), or systems review

HPI

•History of the present illness part of the history section of the H&P report
•Patient's oral history given to the doctor concerning the onset and duration of the illness, as well as any precipitating factors the patient may associate with the condition.

HPI can contain subsections concerning the patients:

Past medical history (PMH), which details any previous major illnesses or related conditions, any chronic illnesses, any previous hospitalizations or surgeries, any prior treatment for the current condition, and the patient's current immunization record (if associated with the illness)

Other HPI subsections:

Can include family, educational and social (such as smoking and alcohol consumption) histories, medications they may be taking or allergies they may have.

Describe the radiology report

•Describes a diagnostic exam or procedure using radio waves or other forms of radiation
•Dictated by the radiologist

What are the major sections of the radiology report?

•Name of the Diagnostic Examination
•Description of the diagnostic procedure, if included
•Findings or the body of the report
•Diagnostic impressions

Sometimes a radiology report can consist simply of:

•The name of the examination/procedure
•Radiologist's impression

The H&P report is generated by:

the admitting physician, resident or hospital internist upon formal admission of an inpatient.

H&P report is broken down into:

2 sections:
1. History - historical component of the report, is a summary of the chronological record of situations, events and other associated topics that may have contributed to the patient's admission into the hospital.
Often considered Subjective, bc it relates to the patients own sense of their condition.

The main section of the OP report is:

The actual Description of the Surgical Procedure, sometimes simply called the Procedure.

What are the major sections of the pathology report?

Major sections of the PATH report are the Gross Findings and Microscopic Findings (Cytology and histology), and the Pathological Diagnosis or diagnoses. The PATH report is a separate report describing specific disease findings and is usually limited to tissue, while lab data usually provide specific information regarding body fluids and their components.

What is the purpose of documenting all encounters, procedures and diagnostic assessments in a patient's chart in medical office (or charting):

The purpose is twofold:
The first role of medical office charting is simply to provide permanent, legible written documentation of the medical record.
The second role charting plays in the medical office is to ensure payment for the physician or medical provider.

Medical offices operate quite differently from hospitals in terms of?

Medical transcription and the documentation of medical records.

In hospitals, patients usually are admitted for a _____ period of time or are seen, receive _____-_____ treatment and are referred elsewhere.

Short, short-term treatment

Each new hospital admission is treated __________, and a new set of _______ is generated for each admission.

separately; reports

In medical offices, patients usually are seen at more ________ intervals. The evaluation and _________ for each visit may be separate, or linked to a previous or future visit, and the patient records in the medical office reflects this continuity.

Frequent; treatment

Notes from one visit may be added to a previous record, or all records may be _________.

combined

Turn around time in a medical office:

Is usually more rigid than in a hospital.

Occasionally a physician's office will ave a turnaround time of 72 hours or more, because:

Medical office patients are seen at more frequent intervals than in hospitals, the physician often will request a turnaround time of 24 hours or less so if the patient comes in for reevaluation all of their records will be posted in the chart.

Without charting, physicians could not be:

paid or reimbursed by insurance companies for their services, and medical office staff could not be paid for their duties

What role has become a sub-specialty in medical offices, that most have personnel or even entire departments are dedicated solely to it?

The financial aspect of health care.

What is the primary function medical transcription serves in ensuring the dr. is paid for services?

Assisting in the proper preparation of all medical records documents for coding purposes.

What is coding?

Coding is transferring the narrative description of diseases, injuries, medical conditions and procedures into numerical designations.

All treatments, services and diagnoses in the medical record must be assigned what?

codes, universally recognized numerical indicators for a procedure, service or diagnosis.

In addition to transcribing the medical record and along with the dr., making sure it is correct and complete, medical transcriptionists are often asked to do what?

Code diagnoses and procedures as they transcribe dictation, so billing and filing insurance claims will be an easier process for the medical records department.

Abstract

break down technical medical information into more simple terms

In large medical records settings such as in a hospital, they often have personnel whose job is to ____ and _______.

code; abstract

Why is it important for transcriptionists to be familiar with coding.

In smaller medical settings such as medical offices, it is often one of the combined duties of the medical transcriptionist to code and abstract medical records.

The reference guide book that establishes the codes for a particular service or procedure is called what?

The Physicain's Current Procedural Terminology, Fourth Edition (CPT-4)

Which book is used for purposes of coding diagnoses?

International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM)

Where should someone look for further guidelines and instruction about coding procedures?

Delmar Publisher's Understanding Medical Insurance, Fourth Edition by JoAnn Rowell

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