To separate a particular subject from the rest of the text we use side headings. In medical transcription we come across various kinds of medical reports also known as work types and these work types carry side headings in them based on the subject. For example, History or History of present illness is a common side heading in any report which carries brief introduction of patient's medical history. Likewise, other headings also go as per the subject in them.
Below are common side headings and the subject they hold in them.
Reason as to why the patient seeks medical advise/intervention. Doctor sometimes dictates exact words of the patient under this heading. Eg: "I am feeling like as if I am going to pass out."
History of Present Illness
Brief introduction of patient's medical condition/history. The patient's information like patient's age, sex, race, cause of visit, previous visits, previous hospitalizations, etc. is dictated. This heading changes to Subjective in case of a SOAP note.
The patient's medical condition at the time of admission.
The patient's medical condition at the time of discharge.
Past Medical History
Previous illnesses of the patient.
Past Surgical History
Previous surgeries of the patient.
The patient's prescribed medication list with dosage. This heading changes based on the work type. For example, heading changes to Discharge Medications if medications are prescribed at the time of discharge, Current Medications if the patient is already on certain medications.
The patient's medication/seasonal/food/environmental allergies are listed under this heading.
The patient's habits like cigarette smoking, alcohol consumption, illegal drugs intake, place of living, marital status, education, employment etc. is dictated under this heading.
Medical history of the closest relatives of the patient to know if the patient's current medical condition is genitically inherited.
Review of Systems
Detailed disease description of various organ systems. This side heading further holds subheadings like Constitutional, HEENT, Endocrine, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary, etc.
Detailed explanation of functioning of various organs of the patient's body. This side heading further holds subheadings like General, HEENT, Neck, Chest/Lungs, Heart, Abdomen, Pelvic, Rectal, Extremities, Neurologic etc. This heading becomes Objective in case of a SOAP note.
Results of radiological studies such as x-ray, CT scan, MRI, ultrasound etc.
Results of laboratory studies such as blood, urine/stool culture and sensitivity etc.
Detailed description of the examinations, tests, and treatment given to the patient during hospital stay.
Arrangements made by the hospital to the patient during discharge. For example the patient can be sent home or transferred to some other hospital based on the patient's condition. In case the patient leaves AMA (against medical advice), doctor may dictate the same under this heading.
Future followup appointment schedule.
The patient's prescribed list of medications at the time of discharge.
Food to be taken at home after discharge.
Restriction of certain activities based on the patient's condition after discharge.
The patient's condition on discharge.
Physician's conclusion about the disease after thorough evaluation.
Steps to be followed to handle the medical condition until next appointment.
The patient's medical condition before the surgery.
The patient's medical condition after the surgery.
Types of surgery performed on the patient.
Anesthesia used during surgery.
Estimated Blood Loss
Loss of blood during surgery.
Biopsy or fluid collection taken during surgery for further laboratory investigations.
Physician assistant checks for sponge, needle and instrument count before closing the wounds to make sure if they have not left any instrument by mistake in the patient's body.
The complications faced by the surgeon during surgery.
Indication for Procedure
Detailed description of the patient's medical condition that lead to surgical intervention.
Description of Procedure
Detailed description of the surgery performed on the patient.
Findings during surgery.
Work types like Psychiatric Discharge Summary has subheadings in Diagnoses such as Axis I, Axis II etc. These diagnoses are called Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Below is the detailed description.
Clinical disorders (depression, schizophrenia, attention deficit hyperactivity disorder etc).
Developmental and personality disorders (mental retardation in childhood, etc).
Critical physical conditions can be the cause of Axis I and II disorders (HIV, cancer, brain injury, etc).
Psychosocial stressors (events of present/past life such as sudden death of loved one, unemployment, loss of job, etc. may have caused mental disorder).
Highest level of functioning rated as GAF (Global Assessment of Functioning). Overall result of above four axes.
There may be many more side headings other than those mentioned above. Hospital to hospital work types may change and based on the work types side headings may change.
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