Understanding Medical Reports – Their Use And Function
From the moment that a person walks into a hospital, clinic or doctors office, medical reports will begin to be compiled on them. Not only will the information gathered for these reports include what basically and most obviously ails them but also reports will be compiled on any number of other issues and items. The end result, is a complete series of reports that cover a persons health of lack of it in its entirety.
SOAP Reports
While the doctor is talking to a patient he or she will be making observations and taking notes on a number of things. Even things that may seem to not have anything to do with the health issues at hand will be noted, such as a patients psychological demeanor. Most of this type of observational information will be included in the SOAP report which stands for (Subjective Objective Assessment Plan).
Medical Transcribers
It is important for a patient to understand that doctors and nurses and any other medical staff for that matter do not write reports in general. There are exceptions however, when a personal report may be written as an answer to an immediate and specific need. However, barring these rare instances, the vast majority of medical reports are written by medical transcribers.
Creating the Report
The job of the medical transcriber is to take all of the data that has been compiled in the form of notes and charts and convert it into a concise and readable report. To do so they must have a well developed understanding of the structure and purpose of medical reports and medical terminology as well.
