HOW TO WRITE A MEDICAL REPORT
- Know that a common type of medical report is written using SOAP method. This stands for Subjective Objective Assessment Plan. The subjective part of the report tells what the patient says about his symptoms in his own words. The objective part of the report details what you see and hear when you observe the patient.
- Assess the patient after observing her problems and symptoms. When you write a medical report, this is where the analysis of the condition is noted. Tell what conclusions can be drawn to assist the diagnosis. Document all the facts accurately and concisely. The information of the report must be timely and confidential so that it can serve a legal document if necessary.
- Write the Plan part of the Medical report. The plan includes the overall treatment any medications used and any other therapies involved in caring for the patient.
- Note any problems when you write the medical report. Write the date and time beside each entry. Enter the medications or treatments as given. Never skip lines when writing a medical report.
- Draw a single line through any error you make when you are writing a medical report. Never erase or white out an entry. Put your initials beside the error line.
GENERAL PRINCIPLES FOR COMPLETE DOCUENTATION IN MEDICAL RECORDS
It is a Medical Transcriptionist job to interpret and transcribe dictations by physicians and other health professionals regarding patient assessment, work up, therapeutic procedures, clinical course, diagnosis etc. But as a physician you must be aware of the general principles for complete documentation of medical records to ensure that these are written or transcribed into a record. The nature and amount of physician work and documentation vary by the type of service performed the place of the service and status of the patient. The following principles are applicable to all types of medical and surgical services in all settings.
- The records must be complete and legible.
- Each patient encounter should include the following documentation:-
- Reason for the encounter
- history, physical examination prior diagnostic test results
- diagnosis (assessment, impression).
- plan for care
- Name of the observer
- sign of the observer
- Rationale for ordering diagnostic or other services, documented or inferred.
- Health risk factors identified.
- Progress and response to treatment, changes in treatment and revision of diagnosis documented.
- The reasons for negative results of X-rays, lab tests and other services should be documented or included.