MT Report Formatting Standards 2

Question 1

In a discharge summary, which section typically follows the 'Hospital Course' section?

Accepted Answer

Condition on Discharge

Answer

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:

Accepted Answer

The radiologist's diagnostic conclusions

Answer

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?

Accepted Answer

Headers (S, O, A, P) are typically typed in all caps or bold

Answer

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:

Accepted Answer

A numeral (e.g., 45-year-old)

Answer

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:

Accepted Answer

Describes what was observed, not the steps taken

Answer

FINDINGS describes intraoperative observations while PROCEDURE details the sequential surgical steps performed.

(MT) Certified Medical Transcription Practice Test