MT Report Formatting Standards 3 — Questions and Answers
Question 1: In a consultation report, the 'REASON FOR CONSULTATION' section is equivalent to which section in a standard H&P?
- Chief Complaint (Correct answer)
- Assessment
- Past Medical History
- Review of Systems
Correct answer: Chief Complaint
The Reason for Consultation mirrors the Chief Complaint by stating why the consulting physician was asked to evaluate the patient.
Question 2: When transcribing vital signs, which format is standardly correct?
- Temperature 98.6, pulse 72, respirations 16, blood pressure 120/80 (Correct answer)
- Temp: 98.6°F / Pulse: 72bpm / Resp: 16/min / BP: 120/80mmHg
- T-98.6 P-72 R-16 BP-120/80
- All formats are equally acceptable per AHDI
Correct answer: Temperature 98.6, pulse 72, respirations 16, blood pressure 120/80
Vital signs are typically listed in a consistent, readable format with the parameter name followed by the value, using the facility's preferred style.
Question 3: A surgeon dictates 'two-by-three centimeter lesion.' How should this be transcribed?
- 2 x 3 cm lesion (Correct answer)
- two by three centimeter lesion
- 2X3CM lesion
- 2-by-3-cm lesion
Correct answer: 2 x 3 cm lesion
Dimensions in medical reports use numerals with the multiplication symbol and standard metric abbreviation: 2 x 3 cm.
Question 4: Which element is NOT typically included in the heading of a formal medical report?
- The transcriptionist's personal home address (Correct answer)
- Patient name and medical record number
- Date of service
- Attending physician's name
Correct answer: The transcriptionist's personal home address
Report headings include patient demographics, dates, and physician information, but never the transcriptionist's personal address.
Question 5: In psychiatry reports, the 'Mental Status Examination' section should be placed:
- Under the Physical Examination section (Correct answer)
- Before the Chief Complaint
- After the Assessment and Plan
- Only in inpatient reports
Correct answer: Under the Physical Examination section
The Mental Status Examination is a specialized part of the physical examination and is placed within or after the physical exam section.
Question 6: When a physician dictates a range of values, such as 'three to five days,' it should be transcribed as:
- 3 to 5 days
- three to five days
- 3-5 days
- Either '3 to 5 days' or '3-5 days' per facility preference (Correct answer)
Correct answer: Either '3 to 5 days' or '3-5 days' per facility preference
Both '3 to 5 days' and '3-5 days' are acceptable formats; the MT should follow the client facility's style guide.
Question 7: The 'PLAN' section of a SOAP note should be transcribed to reflect:
- The clinician's intended treatment, tests, and follow-up actions (Correct answer)
- Only medications prescribed during the visit
- Patient's self-reported treatment preferences
- Insurance authorization details
Correct answer: The clinician's intended treatment, tests, and follow-up actions
The Plan encompasses all intended actions including diagnostics, treatments, referrals, and follow-up instructions.
MT Report Formatting Standards 3
In a consultation report, the 'REASON FOR CONSULTATION' section is equivalent to which section in a standard H&P?