Mt Proper Understanding Medical Records Types Of Medical Reports 1.

MT PROPER Understanding Medical Records Types of Medical Reports 1. History and Physical Examination Report (H & P) 2. Radiology Report 3. Operative Report 4. Pathology Report 5. Request for Consultation 6. Discharge Summary 7. Death Summary 8. Autopsy Report 9. Outpatient Model Report History and Physical Examination - Often called the “H&P” is the starting point of the patient’s “story” as to why they sought medical attention or are now receiving medical attention. Common Physical Exam Procedures • Obvious lesions • Palpable mass(es) • Ulceration • Size (in centimeters or inches) and location (especially if tumors crosses midline) of primary tumors(s) • Swelling or enlargement of any masses or organs (organomegaly, hepatomegaly, splenomegaly, hepatosplenomegaly/HSM) • Fixation of mass • Invasion/erosion of bone Side Note: • Laterality PRIORITY REPORT • Size and number of palpable lymph nodes - Gives overview of • Especially cervical the patient • Supraclavicular Must be • Axillary or inguinal accomplished within • Evaluation of cranial nerves 24 hours • Evidence of “frozen” pelvis HISTORY AND PHYSICAL EXAMINATION TEMPLATE Patient Name: Hospital No.: Room No.: Date of Admission: Admitting Physician: Admitting Diagnosis: of the CHIEF COMPLAINT: Chest, Cardiac,

MEDICATIONS: SOCIAL HISTORY: FAMILY HISTORY: REVIEW OF SYSTEMS: PHYSICAL EXAMINATION: (consist following: Vital signs, HEENT, Neck, Abdomen, RLQ, Rectal, Extremities,

Neurologic) HISTORY OF PRESENT ILLNESS:

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DIAGNOSITC DATA:

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Name of Doctor

Four spaces between last Paragraph and signature rule Double space from signature block to dictator/ transcriptionist initials

SB:xx D: 12/01/2009

Format dates as MM/DD/YYYY

T: 12/01/2009 CC: RADIOLOGY REPORT -

The radiology report is a description of the findings and the interpretation of radiographs and other studies done by a radiologist. RADIOLOGY REPORT Patient Name: Hospital No.: X-ray No.: Admitting Physician: Procedure: Date: PRIMARY DIAGNOSIS CLINICAL INFORMATION IMPRESSION

Side Note: Roentgenography – making records of the internal structure of the body.

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OPERATIVE REPORT Patient Name: Hospital No.: Date of Surgery: Admitting Physician: Surgeons: Preoperative Diagnosis: Postoperative Diagnosis: Operative Procedure: Anesthesia: DESCRIPTION:

PATHOLOGY REPORT Patient Name: Hospital No.: Pathology Report No.: Admitting Physician: Preoperative Diagnosis: Postoperative Diagnosis: Specimen Submitted: Date Received: Date Reported: GROSS DESCRIPTION: GROSS DIAGNOSIS: MICROSCOPIC DIAGNOSIS:

REQUEST FOR CONSULTATION Patient Name: Hospital No.: Consultant: Requesting Physician: Date: Reason for Consultation: BURNING AGENT: *Example TREATMENT PLAN GOALS REQUEST FOR CONSULTATION

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DISCHARGE SUMMARY (Final Progress Note or Clinical Resume) Patient Name: Hospital No.: Admitted: Discharged: Consultations: Procedures: Complications: Admitting Diagnosis: HISTORY: DIAGNOSTIC DATA ON ADMISSION: HOSPITAL COURSE: DISCHARGE SUMMARY: DEATH SUMMARY Patient Name: Hospital No.: Admitted: Deceased: Consultations: Procedures: ADMITTING DIAGNOSES FINAL DIAGNOSES COURSE IN HOSPITAL: DIAGNOSTIC DATA: CAUSE OF DEATH

HISTORY, PHYSICAL, IMPRESSION, PLAN Patient Name: PCP: Date of Birth: Sex: Date of Exam: HISTORY: PHYSICAL EXAMINATION: (HEENT, NECK, CHEST, SKIN, ABDOMEN, EXTREMETIES) IMPRESSION: PLAN:

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AUTOPSY REPORT Patient Name: Hospital No.: Necropsy No.: Admitting Physician: Pathologist: Date of Death: Date of Autopsy: Admitting Diagnosis: Prosector: FINAL ANATOMIC DIAGNOSES PERITONEAL CAVITY: MEDIASTINUM AND THYMUS: PLEURAL CAVITIES: PERICARDIAL CAVITY: HEART: GREAT VESSELS: THYROID: PARATHYROIDS: LARYNX AND TRACHEA: LUNGS AND BRONCHI: GASTROINTESTINAL TRACT: LIVER: GALLBLADDER: PANCREAS: SPLEEN: ADRENALS: KIDNEYS: URETERS AND BLADDER: GENITAL ORGANS: LYMPH NODES: BONES AND JOINTS: BONE MARROW: CRANIAL CAVITY: BRAIN:

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SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN Patient Name:

PCP:

Date of Birth:

Age:

Sex:

Date of Exam: SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

CORRESPONDENCE/LETTER Address and Telephone No. of the Hospital or Clinic Date Name and Address of the Doctor Re: Patient Name Date of Birth Dear Dr. ---: BODY of the LETTER Sincerely, Name of the Doctor Specialization SCG: xx

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