Types Of Medical Records

Medical Transcription News

As a medical transcriptionist you’ll be asked to dictate a variety of medical documents. Some of them are easier to prepare than others, but all types of medical records are important. Some of the types of medical records that you’ll have a hand in preparing as a medical transcriptionist include:

  • Discharge Summaries - A discharge summary is a record of a patient’s care while in the hospital. It is prepared upon discharge.
  • Medical History Report – This report details a patient’s medical history so medical professionals working with a patient can see at a glance what kind of care he has received in the past.
  • Physical Examination Report – Details the results of a patient’s physical exam.
  • Operative Report – A report that details the procedures and findings of a surgery.
  • Autopsy Report – Details the findings of an autopsy.
  • Diagnostic Imaging Report – Detailed notes of radiological care.

There are many more types of medical reports a medical transcriptionist may prepare as a part of her work routine. You’ll need to be familiar with as many as you can if you want to succeed as a medical transcriptionist.

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