The Basic Ingredients

What follows is a list of intelligent building blocks with an explanation of what each subset of information should contain.

Patient Demographics

The patient demographics include the patient's first name and last name (properly spelled and, when necessary, with an indication of which word is the first name and which word is the last name), the patient's medical record number, the date of admission, date of operation, date of transfer, date of discharge, date of death, etc.

Copies

List any physicians, social workers, etc., who should receive copies of the report. Spell their names and, if necessary, give the full address.

Patient care team

This includes the name of the attending physician, referring physician, and any consulting physicians. This may include other healthcare providers such as chiropractors, psychiatrists, podiatrists, herbalists, etc.

Surgical team

On an operative report, this includes the name of the surgeon, assistant surgeon(s), anesthesiologist, and any medical students who are
assisting.

Chief Complaint:

This is the patient's reason for coming to the hospital. In some Emergency Rooms, this is a verbatim quote comprised of the first words that came out of the patient's mouth

This becomes especially important in situations where a patient is in pain, has a language barrier, or speaks in a dialect or form of slang that is unintelligible to the treating physician. Someone who is homeless, demented, screaming in pain, or a member of street gang, may use terms that make no sense or which are alien to the treating physician's vocabulary.

If the patient says "I'm fuckin' dying, goddamnit," or "Hurts like hell, Mon!" the physician should dictate that statement as a quote to the medical transcriptionist.

History of Present Illness

This section includes the onset of symptoms, the symptomatology related by the patient, and anything in the recent past which could have contributed to the presenting illness. If a patient was recently discharged from a hospital, has recently moved to the area, or is traveling on business or vacation, such information should be included in this section.

Past Medical History

This section contains a synopsis of a patient's medical history and should include any chronic diseases such as diabetes, high blood pressure, asthma, as well as motor vehicle accidents and other traumas.

Past Surgical History

Obviously, a history of any surgical procedures ranging from tonsillectomy and adenoidectomy to extraocular lens implantation, below-the-knee amputation, or insertion of a penile implant.

Family History

This section should include any history of hereditary diseases such as cancer, sickle cell anemia, diabetes, etc. It is extremely important to determine whether or not the patient was adopted (many doctors fail to do this).

Social History

This section includes a description of the the patient's living situation. Is the patient married, divorced, straight, or gay? Does the patient live alone, with a spouse, with children, with roommates, in a hotel, or in an extended care facility? List the patient's habits with regard to alcohol, tobacco, marijuana, other recreational drugs, and intravenous drug use. Determine how long the person has lived in the area. If appropriate, inquire about domestic violence or spousal abuse (doctors routinely avoid these questions), and the patient's HIV status.

Occupational History

Explain the patient's occupation and any work-related injuries which may have contributed to his medical record as part of a Workers' Compensation claim.

Current Medications

Describe the medications the patient is currently taking (do not invent names for drugs) and their exact dosages. If a medication is from a foreign country, be sure to spell its name. If the patient is using over-the-counter medications or herbs, try to be specific about what has been ingested and when. Indicate any illicit substances (alcohol, crack cocaine, heroin, methamphetamines, marijuana) that might recently have been ingested, in what quantity, and how recently.

Allergies

Indicate any allergies the patient may have to medications, foods, animals, etc., and describe what types of reactions have resulted.

Review of Systems

Describe any symptoms and/or complaints relating to each of the body's major systems:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal:

Genitourinary

Musculoskeletal:

Neurological:

Physical Examination

Describe any physical findings relating to each of these areas:

General:

Skin:

Vital Signs:

HEENT:

Neck:

Back:

Chest:

Heart:

Abdomen:

Genitalia:

Pelvic:

Rectal:

Extremities:

Neurologic:

Preoperative Diagnoses

Be very specific in listing a patient's preoperative diagnoses as this information is critical to coders and abstracters.

Postoperative Diagnoses

Be very specific in listing a patient's postoperative diagnoses as this information is critical to coders and abstracters.

Anesthesia

List the types and quantities of anesthesia used during a surgical procedure.

Name of Procedure

Be very specific about naming the procedures performed as this information is critical to coders and abstracters.

Preoperative Findings/Indications for Procedure

Describe the symptomatology which indicated a surgical problem, the tests that were run to determine the problem (and their results), and explain why the decision was made to proceed with surgery. Indicate any preparations that have been made for surgery (barium swallows, enemas, etc.) and be sure to indicate that the patient gave his informed consent for the procedure.

Description of Procedure

Give a detailed, step-by-step description of what happened in the surgical suite.

Hospital Course

This section details the patient's clinical course while in the hospital from admission through surgery (if appropriate), and until the time of discharge. If the patient refused further treatment, or left against medical advice, be sure to indicate this in your dictation.

Laboratory Studies

Include all appropriate reports of test results. Be sure to include units of measurement when dictating numbers.

Discharge Medications

List the medications which the patient must take after being discharged. Be sure to give the exact dosages and spell any medications which may cause problems for a medical transcriptionist. If you are using newly-released drugs, or drugs which are in a trial phase, be sure to spell their names for the medical transcriptionist.

Discharge Activities

If a patient has limited mobility following discharge from the hospital, certain activities may be encouraged or discouraged.

Discharge Diet

If a person is being sent home on a specific diet (such as a low-sodium or 1,200-calorie ADA diet) these instructions should be outlined in this section.

Discharge Plan

The discharge plan indicates where the patient is being discharged to home, convalescent hospital, board and care home, skilled nursing unit) and what plans are being made for follow-up appointments with physical therapists, occupational therapists and one or more physicians.

Prognosis

In the case of a patient whose condition is deteriorating, the prospects for continued health should be described in this section. If the patient has requested "Do Not Resuscitate" status for any future admissions, the patient should be identified as a "DNR" or "no code" status.

Discharge Diagnoses

List these diagnoses very carefully as this information is critical to coders and abstracters.

Condition of Patient

Be sure to rate the patient's condition at the time of admission to -- or discharge from -- the hospital.

Next: Ingredients For Standard Reports

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