Question

Research other medical specialist and identify what type(s) of reports they would create, provide a description and purpose for the report.

Answer 1

Answer

A medical report is a complete report that consist a person’s clinical history.

It is an important piece of proof that can validate and support claim for future reference and information purposes

Different types of reports made by the other medical specialist are

Consultation (Consult)

• This report is usually recited by a physician to whom the admitting physician has referred the patient. In certain circumstances consultations are made as requested for second opinions.
• A consultation report includes a short history of the client illness and physical asessment also include laboratory or x-ray findings if any.
• The report usually wraps up with the consulting physician's signature and further plan, and gratitude comment from the consulting physician thanking the admitting physician for the referral.

History and Physical assessment report

• This report is usually recited by the admitting physician or resident when a patient is admitted to the hospital.
• This report initially as chief complaint, history of the present illness, past medical history, social history, and family medical history, Social History or Habits, review of systems and a complete physical assessment from head to toe
• This report usually concluded with an admission diagnosis and further plan for the patient treatment.

Operative Report (OP)

• This report is recited by the operating physician and contains complete details regarding an operative procedure.
• Operative report includes information regarding preoperative and postoperative diagnoses, surgeries that were performed, type of anesthesia anaesthesiologist name, surgeon's name, attending nursing staff, in detail information of operative procedure. Report ends up with where the patient was transferred when he left the operating room (usually recovery room) and the condition of the patient at the time of transfer.

Discharge Summary (DS)

• This report is recited by the admitting physician at the end of the patient’s stay in the hospital.
• Discharge summary includes information about services rendered from admission to discharge, including laboratory and X ray data, pertinent physical findings.
• The report concluded with the discharge diagnosis and a detailed plan for the patient after the discharge.
• In certain condition client will be transferred from one hospital to other institution then we call this report as transfer summary.
• In certain circumstances, if patient death occurs during the hospital stay, the report is known as death summary.

Laboratory reports

This report describes findings of assessment of bodily fluids such as blood levels and urinalysis. Laboratory reports are rarely dictated separately but are often included inside the H&P, consultation or discharge summary.

Pathology Report

This report is recited by a pathologist and describes findings of a tissue sample.

Radiology Report

• This report is recited by the radiologist after a diagnostic procedure and includes the findings and impression of radiologist’s.
• Some of the examples of radiology reports are CT scans, MRI scans, x-rays, nuclear medicine procedures and fluoroscopic studies.