Reference no: EM133713801

Question

Imagine you are helping a new coworker get familiar with the job responsibilities of a Medical Transcriptionist (MT). You have shown them the different kinds of reports in the medical office and explained that medical reports are also called chart notes, outpatient notes, or progress notes. You provided examples of the reports such as a History and Physical Examination (H&P), Operative, Consultation, Discharge Summary, Pathology and Radiology Reports. You explained that these notes are part of the patient's permanent medical record and are vital to effective patient care.

1. Explain how to identify the type of information that appears in various medical reports.

2. Explain how to identify which formats are acceptable when preparing various types of reports using one report as an example.

3. Describe one example of how missing documentation can affect patient care.