Medical Transcription

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01 History & Physical Report

A medical history and physical examination, also known as an H&P, is a formal document that physicians create to assess a patient’s condition and problems. The H&P is a result of a patient interview, physical exam, and a summary of any pending or obtained tests. It’s considered a vital part of patient care and guides future diagnostic and treatment decisions.

02 Consultation Report

A medical consultation report, dictated usually by a specialist, explains a patient’s condition and past history. It also includes the physician’s evaluation of the patient, the consultant’s evaluation, and the consultant’s recommendations. Consultation reports are common especially when a primary care physician refers a patient to a specialist. They are important for effective communication between physicians who refer patients and those who provide specialized care.

03 Operative Report

An operative report, dictated by a surgeon, is simply the summary of a surgical procedure that becomes part of the patient’s medical record. Capturing the details of the surgical procedure, which is the surgeon’s responsibility, is an important aspect of documenting the procedure(s) performed and their medical necessity. Additionally, the operative report, or op report for short, captures the details required to submit a claim to insurance that provides reimbursement to the surgeon, care team, and the facility.

04 Discharge Summary

A discharge summary, dictated by the attending physician, is a detailed report at the conclusion of a hospital stay or series of treatments. It acts as a crucial communication tool, bridging the gap between healthcare and your future medical journey. Essentially, it tells the story of your time in the hospital/health center.

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