Q. What kinds of reports will I be typing in an entry level position as a Medical Transcriptionist?
A. Most entry level positions are found working for doctors in private practice who dictate office notes, letters, initial office evaluations, and history and physical examinations.
Office Notes: The physician will dictate this after talking with, meeting with, or examining a patient. It is sometimes also called progress note, chart note, SOAP note, or followup note, and it is a description of the patient’s problem, physical findings, and the physician’s plan of treatment. It sometimes may include laboratory tests. They vary in length from a couple of sentences to a couple of pages.
Letters: The physician will often use a letter, still considered a medical document, to provide information to another doctor, insurance companies, or government offices regarding a patient.
Initial Office Evaluations: This is dictated after the first visit of a patient and is similar to the History and Physical Examination.
History and Physical Examinations (H&P): This report is more formal than an office note and includes information in regards to the patient’s chief complaint, history of present illness, past medical history, family and social history, review of systems, and the physical examination.
Other reports that may be typed include Consultations (when one physician refers a patient to another), Emergency Room reports (when patient has been seen at the emergency room in the hospital), Discharge Summary (when patient leaves the hospital), and Operative Reports (report of operation performed). Although these are not common in entry level positions, they may be required from time to time.