MT Report Formatting Standards 2 — Questions and Answers
Question 1: In a discharge summary, which section typically follows the 'Hospital Course' section?
- Condition on Discharge (Correct answer)
- Chief Complaint
- Review of Systems
- Social History
Correct answer: Condition on Discharge
The Condition on Discharge section follows the Hospital Course, summarizing the patient's status at the time of leaving.
Question 2: When transcribing a radiology report, the 'IMPRESSION' section should contain:
- The radiologist's diagnostic conclusions (Correct answer)
- Detailed technical imaging parameters
- Patient positioning during the scan
- Insurance billing codes
Correct answer: The radiologist's diagnostic conclusions
The IMPRESSION section contains the radiologist's interpretive conclusions and diagnoses based on the imaging findings.
Question 3: Which formatting standard applies to the use of headers in SOAP notes?
- Headers (S, O, A, P) are typically typed in all caps or bold (Correct answer)
- Headers should be lowercase and italicized
- Headers are omitted when dictated verbally
- Headers must always be followed by a colon and two spaces
Correct answer: Headers (S, O, A, P) are typically typed in all caps or bold
In SOAP notes, the four section headers are standardly typed in all caps or bold to clearly delineate each section.
Question 4: A patient's age in a medical report should be expressed as:
- A numeral (e.g., 45-year-old) (Correct answer)
- Spelled out when under ten (e.g., nine-year-old)
- Always spelled out in full
- In Roman numerals for formal reports
Correct answer: A numeral (e.g., 45-year-old)
Per AHDI guidelines, ages are always expressed as numerals in medical transcription regardless of value.
Question 5: In operative reports, the 'FINDINGS' section differs from 'PROCEDURE' in that it:
- Describes what was observed, not the steps taken (Correct answer)
- Lists the surgical instruments used
- Contains the preoperative diagnosis only
- Includes post-op care instructions
Correct answer: Describes what was observed, not the steps taken
FINDINGS describes intraoperative observations while PROCEDURE details the sequential surgical steps performed.
Question 6: When a dictating physician spells out a patient's name for verification, the transcriptionist should:
- Use the spelled name but verify against the patient demographic header (Correct answer)
- Transcribe the spelling letter by letter as dictated
- Ignore it and use only the patient ID number
- Insert '[name spelled]' in brackets
Correct answer: Use the spelled name but verify against the patient demographic header
The MT uses the spelled name to verify accuracy but formats it normally in the report per the patient's demographic record.
Question 7: Which statement correctly describes the formatting of medication dosages in medical reports?
- Use numerals with the unit (e.g., 500 mg, 10 mL) (Correct answer)
- Spell out dosages under ten (e.g., five milligrams)
- Use abbreviations only (e.g., 5mg with no space)
- Express all dosages as fractions
Correct answer: Use numerals with the unit (e.g., 500 mg, 10 mL)
AHDI standards require numerals for all medication dosages with a space between the number and the unit abbreviation.
MT Report Formatting Standards 2
In a discharge summary, which section typically follows the 'Hospital Course' section?