Physicians dictate various reports on various occasions and these reports are called Work Types. Below are the most common work types dictated by the physicians based on the patient's visit to the hospital.
History and Physical
This report is dictated when the patient gets admitted to the hospital. This report is dictated by the admitting physician. Dictator/physician normally starts the dictation with Chief Complaint then moves on dictating History of Present Illness, Past Medical History, Past Surgical History, Medications, Allergies, Social History, Family History, Review of Systems, Physical Examination, Laboratory Data, Impression/Assessment, and Plan/Recommendations.
This report is dictated when the admitting physician refers the patient to another physician for consultation. Consulting physician dictates this report after consultation. When the admitting physician is not specialized in treating the patient's condition, the patient will be referred to another physician for consultation who is specialized in that subject. The patient can be referred for a second opinion too. Consultation normally starts with Referring Physician/Requesting Physician's name, Reason for Consultation, History of Present Illness and rest of the dictation format is same as History and Physical and this dictation may end with consulting physician thanking the referring physician (Thank you for referring this patient and we will continue to follow with you). Consulting physician may ask for a CC (carbon copy) of the report to be sent to the referring physician.
This report is dictated after operation and/or procedure by the operating physician (surgeon). Dictation consists of detailed description of operation which includes Preoperative Diagnosis, Postoperative Diagnosis, Procedure Performed (Title of Operation, Operation Performed), Surgeon, Assistant, Estimated Blood Loss, Specimens, Fluids Given, Findings, Complications, Indication for Operation, Procedure in Detail (Operation in Detail), Instrument Count.
This report is dictated after the patient is being discharged from the hospital. This report is dictated by the admitting physician. This report changes accordingly, like, if the patient is transferred to some other hospital it becomes Transfer Summary and if the patient is dead while undergoing treatment it becomes Death Summary. This report comprises of the patient’s hospital stay from admission to discharge/transfer/death. Dictation usually consists of Admission Diagnosis, Discharge Diagnosis, Brief History, Hospital Course (medications given, IV fluids given, laboratory studies, radiological studies, physical examination, etc.). This report ends with Discharge Instructions (Activity, Diet, Followup), Condition on Discharge, and Disposition.
SOAP notes are usually short clinic notes or follow-up notes dictated by physicians for a brief update on the patient's present condition. SOAP means Subjective, Objective, Assessment, and Plan.
The above mentioned are the main work types which we come across on a daily basis. Apart from those mentioned above, there are many other reports, like, Progress Note/Followup Note/Clinic Note, Radiology Report, Cardiac Catheterization Report, Psychiatry Report, etc.
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