Standardized Templates

Certain parts of routine hospital reports adhere to standardized templates determined by the hospital's Medical Record Committee. These templates -- which are most frequently used for information regarding the patient's review of systems and physical examination -- have been designed to make it as easy as possible for anyone reading the patient's chart to find the information they need.

These templates are also designed to serve as an "informational road map" for the dictating physician and are aimed at complying with certain standards set by the Joint Commission regarding patient documentation.

Let's look at a sample template used by many medical transcriptionists:

REVIEW OF SYSTEMS:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

By remembering the order of items in this template, a physician should be able to organize his thoughts without much difficulty.

If a physician can consistently deliver information to the transcriptionist in the order which matches the way the items are listed in the template, the process of converting information from spoken to written words should proceed very smoothly.

Next: Follow The Map And You Won't Get Lost

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