|
|
Health Info Home | ITS Home
|
Dictation Format
ALL REPORTS (Header Information)
Please give:
- Your full name and title
- Type of report
- Attending physician's full name with spelling
- Patient's name with spelling
- Medical record number (NOT billing number) 8 digits
Example: 100-00-00/0, 020-00-00/0, 003-00-00/0
- Pertinent dates (admission, discharge, operation)
MISSING OR INCORRECT Header information will cause a delay in reports being interfaced
with POWERCHART.
DISCHARGE SUMMARY REPORTS
Use the following headings in order:
- DISCHARGE DIAGNOSES: List the diagnoses treated in the hospital with number 1
as the primary diagnosis.
- MAJOR THERAPY/OPERATIONS or PROCEDURES: Include operations and
procedures performed while in the hospital.
- HISTORY OF PRESENT ILLNESS: A brief (1-2 line) summary of the patient's illness or cause for hospitalization.
- HOSPITAL COURSE: Briefly summarize the patient's hospital course and treatment
(include major diagnostic, laboratory, and radiographic findings).
- DISPOSITION: Discharge plans, follow up instructions, medications (specify
1. Discontinued pre-admission medications 2. Changes to pre-admission medications 3. New medications), instructions regarding diet, activity, wound care, etc.
OPERATIVE REPORTS
Use the following headings in order:
- PREOPERATIVE DIAGNOSIS: List the diagnoses.
- POSTOPERATIVE DIAGNOSIS: "Same" or further diagnostic findings to preoperative diagnosis.
- OPERATION PERFORMED: Please list operation procedures by number.
- SURGEON: Staff surgeon name and spelling (a copy is sent to the Attending.)
- ASSISTANT: Assistant (co)surgeon(s) name and spelling.
- ANESTHESIA: Type of anesthesia used.
- INDICATIONS*: Reason for surgery briefly stated.
- FINDINGS*: Operative results briefly summarized.
- PROCEDURE: Accurate listing of operative intervention procedures, techniques
*Heading not necessary but may be given.
Instructions
Incentive Program
Helpful Hints
|
|
