Essay on week 2 report

Submitted By JMS030187
Words: 811
Pages: 4

The eight common types of medical reports are the history and physical examination, diagnostic imaging and radiology reports, operative reports, pathology reports, consultations, discharge summary, death summary, and autopsy reports. History and physical examination is done when a patient is admitted into the hospital for evaluations and treatment, the report should include, patient name, patient ID, room number, date of admission/ date of arrival, admitting/attending physician, admitting diagnosis, chief complaint, history of present illness, past history, medications, social history, family history, review of systems, physical examination, diagnostic data, assessment, and physician signature. With diagnostic imaging and radiology reports, radiology is that branch of the health sciences that deals with radioactive substances and radiant energy together with the diagnosis and the treatment of a disease by the means of Roentgen rays or ultrasound techniques. The radiology report is the description of the findings and the interpretations of the radiographs and the other studies that are done by the radiologist. The Radiology/Diagnostic imaging report should include the patient’s name, patient ID, DOB, age, sex, report number, who the ordering physician is, the procedure, date of the procedure, what the primary diagnosis is, the clinical information and physician signature.. Operative reports are done immediately after the completion of a surgical procedure, a record if the procedure must be dictated by the physician, then transcribed and placed in the patient’s files. Preoperative and postoperative diagnoses are included in the report, the body of the report, which includes the findings and procedures, is dictated in a narrative form and it contains information about the patient after the surgery. The operative report should include, the patient name, patient ID, DOB, age, sex, the date of admission, date of procedure, admitting physician, surgeon, assistant, preoperative diagnosis, postoperative diagnosis, operative procedure, anesthesia, specimen removed, IV fluids, estimated blood loss, urine output, complications, a description of procedure, and physician signature. Pathology is the branch of medicine that deals with the study of disease; it is divided into anatomic pathology and clinical pathology. Anatomic pathology is the branch of pathology that tissue reports are issued, the tissue described as both grossly and microscopically by a pathologist. The pathology reports need to include the patient name, ID, DOB, age, sex, pathology report number, date of the surgery, preoperative diagnoses, postoperative diagnoses; specimen submitted, date the specimen was received, date the specimen was reported, clinical history, gross description, microscopic description, microscopic diagnosis, and physician signature. Consults from a physician specializing in different fields of medicine are necessary to provide the proper care for patients, the admitting/attending physician is in charge and maintains continuity of care at all times. The consult reports must include; patient name, ID, DOB, age, sex, room number, consultant, requesting physician, date of consult, reason for consultation, description, treatment plan, goals, and physician signature. Discharge summary is required for each patient who is discharged from the hospital. The discharge report should consist of the patient name, ID, DOB, age, sex, date of admission, date of discharge, admitting physician, consultations, procedure performed, complications, discharge diagnosis, History, diagnostic data on admission, hospital course, discharge diagnoses, discharge medications and the physician