MT Report Formatting Standards 3

Question 1

In a consultation report, the 'REASON FOR CONSULTATION' section is equivalent to which section in a standard H&P?

Accepted Answer

Chief Complaint

Answer

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?

Accepted Answer

Temperature 98.6, pulse 72, respirations 16, blood pressure 120/80

Answer

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?

Accepted Answer

2 x 3 cm lesion

Answer

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?

Accepted Answer

The transcriptionist's personal home address

Answer

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:

Accepted Answer

Under the Physical Examination section

Answer

The Mental Status Examination is a specialized part of the physical examination and is placed within or after the physical exam section.

(MT) Certified Medical Transcription Practice Test

(MT) Certified Medical Transcription Practice Test

MT Report Formatting Standards 3