1. Various medical report formats and styles exist nationwide. On the job, transcriptionists use the report formats ap-proved by their transcription supervisor or department head.
2. Headings. The purpose of headings and subheadings is to categorize medical data so that important information is easy to locate within the report. Generally speaking, the transcriptionist may add headings and subheadings to a dictated report as appropriate.
The transcriptionist should also be alert for important headings that are not dictated but are a vital part of the report, such as Diagnosis or Impression in a history and physical examination report, or Final Diagnosis in a discharge summary, and Preoperative Diagnosis and Postoperative Diagnosis in an operative report. If any of these headings are not dictated, the transcriptionist should supply them and flag the report to the attention of the dictator so that the Diagnosis can be stated.
3. Adding headings not dictated. If a physician dictates a narrative portion that belongs under a particular heading but fails to dictate the heading, the transcriptionist may insert the proper heading. For example, it is not uncommon for physicians to finish dictating the physical examination section of a discharge summary and begin to dictate laboratory test results or x-ray results without giving a heading for a new section. The transcriptionist should paragraph after the Physical Examination and may insert an appropriate paragraph heading such as Laboratory Data or Laboratory and X-ray Data before transcribing the information.
Exception: Some physicians do not dictate an initial heading (Chief Complaint or History, for example) but begin by detailing the events that led to the patient's hospitalization. Because the information at the beginning of a report is distinct and clearly evident, it is not necessary to add a heading here if one is not dictated, although it is acceptable to do so. The transcriptionist on the job would follow the dictator's preference, if such preference is known, or the format specified by the transcription department where the dictation originated.
PHYSICAL EXAMINATION: The fracture site was tender to palpation. He had good sensation and circulation in the leg. Multiple views of the tibia revealed there was a stairstep-type fracture at the distal portion of the tibia. The CBC and differential were normal.
PHYSICAL EXAMINATION: The fracture site was tender to palpation. He had good sensation and circulation in the leg.
LABORATORY AND X-RAY DATA: Multiple views of the tibia revealed there was a stairstep-type fracture at the distal portion of the tibia. The CBC and differential were normal.
4. Abbreviations in Headings. Doctors may take shortcuts by dictating abbreviations, even for major report headings, such as CC (Chief Complaint) and HPI (History of Pres-ent Illness). Headings should always be spelled out in full. Note: Do not confuse a CC dictated for Chief Complaint with the other definitions of the abbreviation cc: cubic centimeter and carbon copy.
5. Diagnosis/Diagnoses. If a physician dictates the singular form Diagnosis and then lists several diagnoses, the transcriptionist may use either Diagnosis or Diagnoses to head the list.
6. Numbered diagnoses listed vertically. Physicians frequently number the diagnoses and want them listed vertically for ease in reading. The transcriptionist may elect to enumerate a long list of diagnoses, whether or not numbers are dictated. Occasionally a dictator will begin to number the diagnoses and then give only one diagnosis; in that case, omit the number (no need for a 1 without a 2). Be aware that in listing several diagnoses, dictators often lose track of the next number. They may inadvertently give the wrong number (which should be corrected by the transcriptionist) or delegate the numbering to the transcriptionist by saying "number next" to indicate the next diagnosis.
7. Varied acceptable formats. There are several acceptable formats for medical reports, and even alternative acceptable formats for the same sentence.
Dictated: Extremities unremarkable.
The extremities are unremarkable.
EXTREMITIES: The extremities are unremarkable.
8. Paragraphing. Transcribe paragraphs as dictated unless paragraphing would alter the medical meaning or continuity of the report. Paragraphing may be added to break up long reports appropriately, to set up a new heading and its accompanying paragraph, and to separate the findings from the operative procedure. Be aware that when some physicians dictate "new line," they mean to begin a new paragraph.
9. Standard formats. With the advent of computers, many hospitals and clinics have instituted standard format outlines for each type of report dictated. These are stored in the computer's memory as templates that can be "pulled up" by the transcriptionist. This practice has introduced greater conformity in format style within an institution and has made adjusting and remembering formats relatively painless.