Saturday, June 8, 2013

How To Write Medical Transcription Reports For A Patient

By Lucille Lamb

It is necessary for the doctor to keep records of the all the people he attends to; medical transcription reports are helpful to make these records. This is usually used in future if he will visit the hospital again. They are kept for future use if there will be any need to refer to the information. This will help to maintain the record of the patient.

A person who will be in charge of writing this report should have a tape from the doctor where the summary on the health of the patient is recorded. You should open this tape on the word processing software. You have to get all the details and this is why you have to use a headset so that you will get all the necessary information. This will help you to get the details that are important in writing the report.

You will have to put the details for the patient, physician and the hospital on the upper part of the template. You then start the machine by pressing the pedal to listen to what was recorded about the patient. You have to make the necessary changes that include correction of any word that has been spelt wrongly. You have to be very careful when preparing this report as it is supposed to be very accurate.

To the body of the report you are supposed to do some tests and examinations. You have to put an extra section where you will include what the doctor thinks about the condition that the patient is going through. You will also have to include the tests which the doctor took and on the visits that he has been advised to go for.

It is important that the doctor signs the document; this is why there should be some space for this purpose. Details of the contact and hospital should follow after the signature. Including this is important as such details will be used if the doctor is needed urgently. The signature will confirm that the procedures were taken by a specific person.

At times the client requires the report to be in a specific format. You can tell him to give you a sample so that you can see how you are supposed to write the report. The instructions given by the client should be used to get the required report.

All details about the illness of a person should be kept a secret. Such information is usually protected by the law and if you do a mistake and leak them out then you may have to deal with the law. To avoid this you should adhere to the rules that you have been given by the client. You should not tell anybody about the status of anybody as this should be kept a secret.

Medical transcription reports are delicate and they should be handled with care to get the required report. These records will be helpful to find out what the doctor wrote about the health of the person. It is necessary that they are prepared with the accuracy required. All the information has to match the summary that was written about the patient in every word without changing anything.

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