| Consultation Report Tutor Review Continuing our medical transcription overview -- a physician that specializes in a specific area of medicine may be asked to do an evaluation on a patient. An example list of names of "medical specialists" are listed below: Cardiologist Endocrinologist Neurologist Urologist Pediatrician Obstetrician Allergist Psychiatrist Surgeon Possible Headings and Subheadings of a Consultation Report CONSULTATION REPORT REASON FOR REFERRAL: HISTORY OF PRESENT ILLNESS: PAST MEDICAL HISTORY: MEDICATIONS: ILLNESSES: OPERATIONS: ALLERGIES: FAMILY HISTORY: REVIEW OF SYSTEMS: SKIN: HEENT: CARDIORESPIRATORY: GASTROINTESTINAL: GENITOURINARY: GYNECOLOGIC: NEUROPSYCHIATRIC: MUSCULOSKELETAL: GENERAL: VITAL SIGNS: HEENT: CHEST: HEART: LUNGS: ABDOMEN: PELVIC: (optional) RECTAL: (optional) EXTEMITIES: NEUROLOGIC: DATA BASE: ASSESSMENT: PLAN: Discharge Summary Tutor Review A Discharge Summary is a report that summarizes the patient's hospital stay. This report documents any procedures, laboratory tests, x-rays, medical treatments and medications given during the course of the hospitalization. The end of the report often includes recommendations, plans and follow-up care instructions for the patient. Possible HEADINGS and SUBHEADINGS for the DISCHARGE SUMMARY DISCHARGE SUMMARY ADMITTING DIAGNOSIS: HISTORY OF PRESENT ILLNESS: PERTINENT PAST HISTORY: LABORATORY FINDINGS: HOSPITAL COURSE: DISPOSITION: FOLLOW-UP: CONDITION ON DISCHARGE: DISCHARGE DIAGNOSIS: PROGNOSIS: DISCHARGE MEDICATIONS: |
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