An operative report details a surgery.
Report writing, especially that which pertains to the health profession, is a tedious task. Luckily for doctors, who are already pressed for time, professional transcriptionists document all patient-related data dictated by physicians. Medical transcription (MT) is an allied health profession that deals with converting medical voice-recorded reports into text format. The "big four" refer to the four major types of medical reports, which form the basis of the major portion of all hospital and health care dictation.
History and Physical Report (H&P)
The history and physical report details a patient's medical history and results of a physical examination. The purpose of an H&P report is to understand the past history of a patient and examine his current complaints to form an appropriate treatment plan. The main sections of a history and physical report include the patient's chief complaint(s), past history, present illness, family history, social history and review of systems. The H&P report is typically dictated by an admitting physician and completed by a health practitioner after a new patient is admitted to a clinic, hospital, health facility or office.
Consultation Report
A consultation report (CONS) is typically requested from a patient's primary physician, by a specialist, for a second opinion regarding a diagnosis or illness. CONS reports include the physician's evaluation of a patient, the consultant's evaluation of the patient and her condition, and recommendations by the consultant. A consultation report can also include contents of the patient's family history and physical report as well as a detailed entry on her medical history.
Operative Report
Operative reports are used to detail the events of a surgical procedure or operation. They formally document surgeries and detail items such as who performed a particular surgery, who assisted the surgeon, the preoperative diagnosis, postoperative diagnosis, description of the surgery, notable intraoperative findings, blood loss during surgery, the patients experience during anesthesia and the surgery, how the patient tolerated the surgery and complications, if any. Operative reports are commonly dictated by surgeons in charge and transcribed by allied health professionals. They are prepared immediately after surgery.
Discharge Summary
Discharge summaries are dictated by physicians in charge when a patient is being dismissed from a clinic, hospital or similar setting. It contains an overall review of the hospital stay and why the patient was admitted. Discharge summaries may also contain follow-up instructions, medications, prognosis and discharge condition of the patient and related laboratory data.
Tags: history physical report, allied health, clinic hospital, dictated physicians, Discharge summaries, evaluation patient, family history
