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Chapter 2
Understanding Medical Documents
Importance Medical Reports 1
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The transcribed medical report is a legal
medical document that communicates
the patient’s health status.
Medical records provide documented
evidence of a patient’s medical
treatment to insurance companies, for
federal and state regulatory
requirements.
Importance Medical Reports 2
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Medical records are vital records for
your employer’s accounting department.
Medical reports dictated in office
practice, hospital, and inpatient facilities
have similarities and differences.
Medical Reports in Inpatient
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history and physical examination
operative report
consultation
discharge summary
* These records are referred to as the “big four”
Medical Reports in Outpatient
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Consultation letters
Chart notes
History & physical examination reports
Diagnostic imaging reports
Procedure reports
Information for identification
Each report must include:
 Patient’s legal name
 Date of birth
 File number (ex. Social Security No.)
Formatting Signature Lines
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Method 1. The physician’s or dictator’s
name is followed by the initials of the
transcriptionist on the third or fourth
line below the last entry line.
Method 2. The physician’s or dictator’s
initials are followed by the initials of the
transcriptionist, the date of dictation,
and date of transcription.
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METHOD 1
Potter T. Bucky, MD
Potter T. Bucky, MD/cd
METHOD 2
Potter T. Bucky, MD
Potter T. Bucky, MD/cd
ptb:XX
D: 11/20/xx (date the report was dictated)
T: 11/21/xx (date the report was transcribed)
Outpatient Medical Documents

Chart Note (Progress Note or Follow-up
Note)
Dictated by a physician after talking,
examining, or meeting with the patient.
Chart Note 1
The chart note contains:
 Precise description of the patient’s
major presenting problem (chief
complaint)
 Physical findings
 Physician’s plan of treatment.
Chart Note 2
It may also include:
 Results of laboratory test
 Results of x-ray test
The Look of Chart Notes
FORMAT
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Margins = 0.5 inches
Single spacing
No blank lines separating the topics
* In this textbook you will format the chart notes
and other medical documents in block style using
1-inch margins, single spacing, blank lines
separating the topics which are capitalized.
Pointers
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Be sure that the patient’s name is
spelled correctly.
The document is dated with the month,
day and year of the visit.
Statistical Data Format on
Chart Notes
1

Statistical data for the first page:
Patient Name: Doe, Jane
Date of Birth: December 21, 1952
Examination Date: April 1, 20xx
Statistical Data Format on
Chart Notes
2
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Statistical data for continuation pages:
Patient Name: Doe, Jane
Date of Birth: December 21, 1952
Page 2
Chart Notes Using the
SOAP Format
A common chart note format is
the SOAP method.
Subjective
S:
Subjective findings that are typically
associated with what prompted the
patient to seek medical care. A patient
will describe feelings and symptoms to
the physician.
Example:
My head and throat hurt and I have been
throwing up all day.
Objective
O
: Objective findings are measurable
findings discovered by the physician or
by the results of diagnostic studies or
laboratory tests.
Example:
Temperature is 103.2ºF, and throat
culture is positive.
Assessment
A
: Assessment is the physician’s
diagnosis or diagnoses of the patient;s
disease or condition, based on
subjective and objective findings.
Example:
Strep throat.
Plan
P
: Plan is the treatment plan
developed by the physician relative to
the findings of the subjective and
objective assessment of the patient.
Example:
Amoxicillin 250 mg t.i.d. X 10 days.
Chart Notes Using the
History and Physical (H&P)
Format
H&P Format
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1
Format 1
History of present illness (abbreviated HPI)
Past medical history (abbreviated PMH)
Physical exam (abbreviated PX, PE, or CPX)
Impression (abbreviated IMP)
Plan (abbreviated RX)
H&P Format
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Format 2
Chief complaint (abbreviated CC)
Past medical history
Physical exam
Laboratory
X-ray
Diagnosis (abbreviated DX)
Treatment (abbreviated TX)
2
History and Physical
Examination Reports
The dictation style of history and physical
examination reports contains recurrent
phrases and terms. It also contains more
negative than positive statements.
Characteristics of H&P and
Chart Notes
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Tendency to condense and
abbreviate
Short and cryptic
Clipped sentences which lack
subject or verb
Clipped Sentence Structure
CHEST : Clear to percussion and
auscultation. Heart regular rate and
rhythm.
ABDOMEN : Flat, soft, nontender,
nondistended, normoactive bowel
sounds.
RECTAL : No masses. Guaiac negative.
Clipped Sentence Structure
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This means: The chest was clear to
percussion and auscultation. The heart
rate and rhythm were regular. The
abdomen was soft, nontender, was not
distended, and had normal bowel
sounds. The rectal exam was negative
in that no masses were found, and the
guaiac test found no occult blood in the
feces.
Formatting Statistical Data on
History & Physical
Examination Reports
Statistical Data on H&P
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First Page:
Patient Name: Doe, Jane
File Number: 00912
Date of Birth: December 21, 1952
Examination Date: April 1, 20xx
Physician: Potter T. Bucky
Statistical Data on H&P
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Continuation page:
Patient Name: Doe, Jane
File Number: 00912
Date of Birth: December 21, 1952
Examination Date: April 1, 20xx
Physician: Potter T. Bucky
Page 2
Topics Included in the
“History” Heading of a History
and Physical Examination
Report
Pointers
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The H&P report is divided into two
headings: “History” and “Physical”
Topic headings are formatted in all
capital letters.
H&P Exam Report Topics
HISTORY
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Chief complaint is the
specific reason for which the
patient sought medical care,
stated in the most concise
terms or sometimes quoted
in the patient;s own words.
History
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History of present illness
contains all historical
information that was given by
the patient concerning the
illness. This information includes
all relevant symptoms and their
duration and any remedies that
have been attempted.
Past Medical History
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Includes information about previous
illness, injuries, surgeries, and chronic
conditions a patient may have had,
along with any allergies to medications.
This topic may also include
immunizations.
Allergies
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Is a list of the patient’s allergies.
Allergies are keyed in either all capitals,
boldfaced, or underlined to call
attention to their importance. The
format varies by facility. Medications
may be included in this section or under
a separate heading.
Medications
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Is a list of medications that the patient
is currently taking. Sometimes this
information is not listed as a separate
topic but included under “Past Medical
History” or “Allergies”.
Family History
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Consists of information about any
hereditary or familial diseases.
Social History
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Is included if the physician believes this
information is pertinent to the patient’s
treatment plan. This topic may include
lifestyle habits such as smoking, and
drinking, as well as the patient’s
occupation, hobbies, family structure,
and living arrangements.
Review of Systems (ROS)
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Includes a brief review of any relevant
information about each major body
system. Depending on the patient’s
problem, this topic can be very
comprehensive and divided into
subtopics such as HEENT,
cardiovascular, respiratory,
gastrointestinal, genitourinary,
gynecologic, neuropsychiatric, and
Continuation…
musculoskeletal, or it may be combined
into one paragraph or simply be a brief
statement such as “noncontributory”
when all systems are negative.
Topics included in the
“Physical Examination”
Heading of a H&P
Examination Report
Physical Examination report
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The “Physical Examination” heading of
the report is exactly what its name
implies. The physician completes a
physical examination of the patient, and
the findings are transcribed under the
pertinent topic. The major topics for
the physical examination of the report
include the following:
General section
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The general section discusses the
appearance of the patient such as
pallor, gait, mood, and personal
hygiene. It also includes a statement of
the patient’s vital signs (blood pressure,
temperature, pulse, and respiration).
HEENT
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Is an abbreviation for the head, eyes,
ears, nose and throat.
Neck
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The neck is palpated for enlargement of
the lymph nodes or thyroid gland,
assessment of the carotid pulses, and
distention of the jugular veins.
Chest
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The chest also includes the thorax,
breasts, and axilla areas.
Lungs
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The lungs are evaluated by
auscultation, during which the physician
listens with a stethoscope to air moving
in and out of the lungs. Diseases or
injury can produce abnormal changes in
the quality and volume or loud ness in
breath sounds. The physician also may
perform the percussion (tapping)
maneuver.
Heart
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The heart is evaluated with a stethoscope
for any abnormal sounds, such as
murmurs or bruits (sound or murmur
heard in auscultation), clicks (brief, sharp
sounds, especially any of the short, dry
clicking heart sounds during systole), rubs
(sounds cause by rubbing together of two
serous surfaces), thrills (vibrations), and
gallops (disordered heart rhythm).
Abdomen
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The abdomen is assessed by
auscultation, in which the physician
listens for any abnormal bowel sounds,
and percussion, in which the physician
palpates the abdomen for tenderness,
guarding, and masses.
Pelvic
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The pelvic region or genitalia are
examined. Women may undergo a
bimanual pelvic exam and Papnicolaou
(Pap) smear.
Rectal
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The rectal exam involves a digital
evaluation of the rectum for deformity
or masses. The physician also may
comment on the results of a guaiac test
(for occult blood) or colonoscopy
(fiberoptic instrument) in this topic of
the report. Men may undergo a digital
rectal examination of the prostate.
Digital palpation is a useful method for
detection of early prostatic carcinoma.
Exremities
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The extremities are examined for
developmental or traumatic deformities,
muscle wasting, and stiffness. The
bones, joints, and muscles of all
extremities are evaluated.
Neurological
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The neurological examination is a
systematic evaluation of the nervous
system, including mental status,
functioning of the cranial nerves and
reflexes, and sensory and
neuromuscular function. The Babinski
reflex and deep tendon reflexes (DTRs)
are usually checked.
Laboratory Data
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Include laboratory test results, such as
complete blood count (CBC), white
blood cell count (WBC), and urinalysis
(UA).
Impression
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Is the physician’s diagnosis or
diagnoses of the patient’s clinical
condition or disease based on the
findings of the physical examination and
diagnostic tests.
Plan of Treatment
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Is developed by the physician based on
the findings of the physical examination
and diagnostic tests.
Diagnostic Imaging Reports
and Letters
Diagnostic Imaging Reports
Diagnostic imaging reports include:
 Clinical radiology (x-ray)
 Ultrasonography (US) or sonography
 Computerized tomography (CT)
 Nuclear medicine (NM)
 Magnetic Resonance imaging (MRI)
Each area is classified as a separate
imaging modality because each uses a
different type of energy and recording
device to image the body.
A compute is involved in the imaging
process of almost all differing
modalities. Hence the image can be
displayed on a video monitor and
then digitally stored or printed on
traditional x-ray film. All modalities
except diagnostic x-ray have crosssectional image recording capabilities.
Diagnostic X-rays
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Diagnostic x-rays use low levels of
radiation to record images of the body
on x-ray film. Newer methods
sometimes allow the image to be
digitized and stored in a computer.
Ultrasound
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Ultrasound or sonography uses highfrequency sound waves to image the
body. It is unique in that it does not
expose patients to ionizing radiation
and therefore is the modality of choice
to evaluate maternal or fetal anatomy in
pregnant women.
Nuclear Medicine
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In nuclear medicine the energy source
is a radioactive isotope that is injected
into the patient’s body, and then
specialized computers and cameras
record and store the image.
Computerized Tomography
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Uses a combination of radiation and
computerized imaging techniques to
record and display an individual’s
anatomy. It is sometimes referred to as
CAT scan (computerized axial
tomography). This term is technically
incorrect because today’s CT scanners
can image the body in more than just
the axial plane.
Magnetic Resonance Imaging
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Is a very sophisticated machine that
uses a magnetic field and radiofrequency waves to generate an image.
It does not use ionizing radiation and
often produces sharper soft-tissue
images than other modalities.