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Transcription Tutor Review on the "Big Four" Reports and Chart Notes: HISTORY AND PHYSICAL EXAMINATION CONSULTATION OPERATIVE REPORT DISCHARGE SUMMARY CHART NOTES HISTORY AND PHYSICAL EXAMINATION An H&P report is always dictated when a patient is admitted to the hospital. The patient's explanation of his medical condition, or diagnosis is important. The content of the report includes information regarding the patient's subjective and objective symptoms. I will list and explain the common headings under an H&P report. CHIEF COMPLAINT: The chief complaint is the patient's main reason or problem for going to their physician or hospital to seek medical attention. An example would be, "I woke up this morning with some chest pain, shortness of breath and felt a little dizzy." Another example: "I have had stomach pain, diarrhea, vomiting and fever for two days." HISTORY OF PRESENT ILLNESS: This heading includes the details about the patient's condition and what led up to coming in for the medical evaluation. PAST MEDICAL HISTORY: This heading includes all of the past medical conditions and surgeries that the patient has had since the time of childhood to present. It also includes a list of medications the patient may be taking and allergy information. This section may also include FAMILY HISTORY, which describes the medical condition of the patient's parents and other family members. An example would be, "My father died at age 75. He had diabetes and a heart condition." SOCIAL HISTORY, including HABITS describes the patient's current lifestyle, including occupation, the use of caffeine, nicotine, alcohol or illicit drugs. I will list some additional common subheadings below: MEDICATIONS OPERATIONS ALLERGIES REVIEW OF SYSTEMS: HEENT (Head, Eyes, Ears, Nose, Throat) CARDIOVASCULAR OR CARDIORESPIRTORY GASTROINTESTINAL GENITOURINARY NEUROLOGIC PSYCHIATRIC (OPTIONAL) PHYSICAL EXAMINATION GENERAL (APPEARANCE) VITAL SIGNS: PULSE, RESPIRATORY RATE, BLOOD PRESSURE SKIN CHEST: HEART, LUNGS, BREASTS (OPTIONAL) ABDOMEN EXTREMITIES PELVIC (OPTIONAL) NEUROLOGIC MENTAL STATUS (OPTIONAL) IMPRESSION RECOMMENDATIONS OR PLAN The upcoming medical transcription tutor review will discuss the CONSULTATION REPORT, followed by OPERATIVE REPORT, DISCHARGE SUMMARY and CHART NOTES. |
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