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Medical Record Templates

Posted on:8/25/2005
Website: http://www.spinetglobalsolutions.com/
A medical record template constitutes one of the most important aspects in medical record transcribing. Usually, such templates are provided by the hospital or clinician as per their requirements.


GENERAL ACCEPTED RULES FOR MEDICAL RECORD TEMPLATE:

A medical record template constitutes one of the most important aspects in medical record transcribing. Usually, such templates are provided by the hospital or clinician as per their requirements. Hence, any change in the format or style of a template provided is totally unacceptable. So, it is necessary to know and understand the importance of a template, the key information it should contain and what are the general rules and formatting style to be followed while designing a medical record template. Some of them are listed below

By default, all templates and records manufactured on the computer should be legible, clear and decent looking when it is presented as a hard copy.

Reports should either be justified or left aligned as per the requirements.

Each report is usually divided in to three parts; the upper half (containing all informative script), the body of the report (containing the actual and valuable information of the patient, examination and action or treatment taken) and the lower half (consisting of doctor’s initial and transcript and transcribers information).

The upper half of the report can be divided in two parts

Physician or hospital information.

Patient information.

The body of the report usually starts with the report heading, e.g. Radiology report, consultation note, discharge summary etc.

After this starts the body of the report, which displays the actual patient specific findings on that visit to the doctor, which depends on the type of the report. View our sample reports.

It is usually obligatory or rather a standard rule to leave atleast four blank lines between the end of the body and doctor’s initials.

The lower half of the report starts with doctor’s signature line and name usually flushed to the left.

After the doctor’s name and signature, with a space starts the transcribers and file information.

The illustration below shows an ideal report format.

(Name Of The Hospital Or Clinic- Usually Bold And Capital)

(Branch, Address, Telephone)

PATIENT NAME: MARK, JAMES HIP #: 000000075906

VISIT DATE: 08/10/05 PATIENT CENTER: XXX

FAMILY PHYSICIAN: SMITH, GEORGE REFERRING PHYSICIAN: CHAPPEL, IAN

Consultation NOTE (Report heading)

HISTORY: Mr. Allen is a 40-year-old gentleman who came with a history of tearing and redness of the eyes.

EXAMINATION: On examination, corrected acuity 20/30 OU. Applanation pressure at 3:45 is OD 13, OS 16. There is a correction factor of +1 for both eyes with a resultant pressure of 14 OD and 17 OS. The anterior segment is quiet and unchanged.

PLAN: Continue present medication and recheck in three months.

___________________

Allen P. Schwartz, M.D.

DD: 08/12/05

DT: 08/13/05

(File name or number)

MT/PR/QA

cc:

Enc: 2

DD = Date of dictation.

DT = Date of transcription.

MT = Medical transcriber’s initials

PR = Proof reader’s initials

QA = Quality Assayist or Editor’s initials

cc = Carbon copy or courtesy copy if any

Enc: Enclosures (write the number of enclosures or description)

So, remember the next time when you design a template for your physician, please make sure that all the instructions are followed and the report looks legible, decent and choreographed properly.

RULES FOR SECOND PAGE FORMATTING:

Many a times the dictations go to second page. So proper care should be taken while transcribing the second page of the report. Many a times, because of improper filing, the second page of the dictation misses out. Hence it is imperative to mention patient information on the second page. This helps a great deal in prevention lost and incomplete dictations.

The second page should usually start with

Mark, James

08/10/05

Page 2

 

View a few of the sample reports dictated every day and the general styling and formatting followed for them.

Letter

Consultation Note

Discharge summary

Operative Report

Radiology Report

Autopsy Report


  
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