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hospital medical reports

History and Physical (H&P): Medical reports such as this are usually dictated by the admitting physician or resident when a patient is admitted to the hospital. It usually begins with a chief complaint. The “history” includes a history of the present illness, past medical history, social history, and family medical history. Smoking can go under the heading of either Social History or Habits. There is usually a review of systems and a complete physical examination from head to toe. The report usually ends with an admission diagnosis and a plan for the patient’s treatment. (Click here to see a sample H&P report)

Consultation (Consult): This report is usually dictated by a physician to whom the admitting physician has referred the patient. Therefore, the consulting physician is usually a specialist in an area other than the admitting physician. Sometimes consultations are requested for second opinions. Consultation reports usually include a brief history of the patient’s illness and a specific physical exam depending on the particular type of consultation requested. The report may also include laboratory or x-ray findings. The report usually ends with the consulting physician’s impression and plan, and sometimes a comment from the consulting physician thanking the admitting physician for the referral.
(Click here to see a sample Consultation report.)

Operative Report(OP): This report is dictated by the operating physician and contains detailed information regarding an operative procedure. Included in this report are preoperative and postoperative diagnoses, the type of surgery or surgeries that were performed, the names of the surgeon(s) and attending nursing staff, the type of anesthesia and the name of the anesthesiologist, and a detailed description of the operative procedure itself. Depending on the operative procedure, information regarding instrument counts, sponge counts and blood loss are also dictated. Often the report will end with disposition or where the patient was transferred when he left the operating room (usually recovery room) and the condition of the patient at the time of transfer. (Click here to see a sample OP report.)

Discharge Summary (DS): This report is dictated by the admitting physician at the end of the patient’s stay in the hospital. It includes a summary of everything that occurred from admission to discharge, including laboratory data, x-ray data, and pertinent physical findings throughout the hospital course. The report usually ends with the discharge diagnosis and a detailed plan for the patient. If the patient is transferred to another institution (such as a nursing or other hospital), the name of the report is usually changed from discharge summary to transfer summary. If the patient has expired (died) during the hospital stay, the report is usually called a death summary. (Click here to see a sample Discharge Summary report.)

Radiology Report: This report is dictated by the radiologist upon completion of a diagnostic procedure and includes the radiologist’s findings and impression. Examples of radiology reports are x-rays, CT scans, MRI scans, nuclear medicine procedures and fluoroscopic studies. (Click here to see a sample Radiology report.)

Pathology Report: This report is dictated by a pathologist and describes findings of a tissue sample. The focus of the report is on the microscopic findings and the pathological diagnosis of the sample. (Click here to see a sample Pathology report.)

Laboratory Report: This report describes findings of examinations of bodily fluids such as blood levels and urinalysis. Laboratory reports are rarely dictated separately but are often included inside the H&P, consultation or discharge summary. (Click here to see a sample Lab report.)

Miscellaneous Reports: Other miscellaneous hospital reports include cardiac catheterizations, electrophysiology studies, phacoemulsification, autopsies and psychological assessments. (Click here to view some sample miscellaneous reports.)

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