The ‘Big Four’ in Medical Transcription Reports Preparing accurate medical reports is crucial for diagnosis and treatment as well as for compliance and reimbursement. To focus on the core task of patient care and ensure timely and error-free documentation, physicians often send their dictated reports to a professional medical transcription company. Four major types of medical reports – referred to as the ‘Big Four’ - form the basis of all healthcare dictation. These are the History and Physical (H&P) Report, Consultation (CONS) Report, Operative Report, and Discharge Summary. Let’s take a closer look at each of these reports. History and Physical Report (H&P) This report describes patients’ medical history and the results of a physical examination, which helps doctors to understand the past history of a patient and examine the current complaints based on that to develop an appropriate treatment plan. The H&P is the intake form used by hospitals, clinics and physicians when a patient is seen for the first time and the first document to be added to the medical record of a patient. It plays a vital role in an emergency situation (for example, the surgeon needs this report in hand when a patient arrives in the operating room) and in treating health problems that result from past events (for example, psychiatric and substance abuse cases). The degree of detail in this report depends on the nature and complexity of a patient’s condition. While the H&P report of a patient with a straightforward, self-limiting problem can be quite brief, a report of a patient with
multiple chronic conditions, acute illnesses or injuries could have exhaustive details. However, the main sections of H&P report include the patient’s chief complaint(s), past history, present illness, family history, social history and review of systems. Consultation Report Consultations are quite frequent in hospitals where an emergency room (ER) physician calls for a specialist after making an initial assessment. The specialist services could be for a psychiatric evaluation, a cardiology assessment or advice on managing kidney failure. Primary care physicians also call for a specialist for further evaluation of a patient. The consultation report includes the physician’s evaluation of a patient, the consultant’s evaluation of the patient and his/her condition, and the consultant’s recommendations. The contents of patient’s family history and physical reports and a detailed entry on the patient’s medical history may be also included in the report. Operative Report The operative report details the events of a surgical procedure or operation and is typically dictated by the surgeon in charge. This report is prepared immediately after the surgery. A full operative report includes the following details:
Pre- and postoperative diagnoses
Names of physicians and assistants involved in the surgical procedure
Title of the surgical procedure performed
Type of anesthesia used
Reason for the procedure performed
Notable operative findings
Step-by-step
narrative
description
of
the
procedure
including
which
instruments used, what specimens or tissues removed, any hardware or devices inserted, wound closure and the details of bandaging
Complications or unexpected developments encountered during the procedure
The condition of the patient at the end of the procedure and where the patient was taken later
The level of detail will be based on the complexity of the procedure. Some reports break up topics with a specific heading for each while others may include pre- and postoperative diagnoses, procedure name, and a long narrative encompassing every other detail. The report should be transcribed exactly as dictated. Discharge Summary
The discharge summary is required when a patient is being discharged from a clinic, hospital or similar kind of setting. It is typically dictated by physician in charge and includes an overall review of patient’s stay and why the patient was admitted. This report may also include medications, prognosis, follow-up instructions, discharge condition, and related laboratory data. If the patient dies in the health care setting, a death summary will replace the discharge summary. Though the death summary has subsets similar to a typical discharge summary, it differs in the following ways:
‘Discharge Date’ changes to ‘Date Expired’ or ‘Date of Death’
‘Discharge Diagnoses’ changes to ‘Final Diagnoses’
Cause of Death may be dictated as an explicit heading based on whether the exact cause was known or unknown during the dictation of the death summary (at certain times, a pending surgical pathology report or autopsy record is required to confirm what caused the death)
The death summary will also include information on whether the patient’s family had consented to an autopsy and whether the patient had a living will that called for no aggressive therapy or ‘do not resuscitate’. If there is no living will, the family or next kin of the patient can take a decision on the matter and death summary would include this information too.