MT Report Formatting Standards 4

Question 1

In a pathology report, the 'GROSS DESCRIPTION' section refers to:

Accepted Answer

Macroscopic examination findings visible to the naked eye

Answer

Gross description documents the physical characteristics observed during macroscopic examination before microscopic analysis.

Question 2

When transcribing a death summary, which date must be clearly documented as a separate field?

Accepted Answer

Date and time of death

Answer

The date and time of death is a required and separately formatted field in all death summary documents for legal and medical-legal purposes.

Question 3

Which formatting rule applies to suture sizes in operative reports?

Accepted Answer

Use numerals and hyphens (e.g., 0-Vicryl, 2-0 Prolene)

Answer

Suture sizes use numerals with hyphens according to AHDI standards, distinguishing sizes like 0, 2-0, 3-0 clearly.

Question 4

A physician dictates 'the patient is status post appendectomy.' This phrase should be transcribed as:

Accepted Answer

status post appendectomy

Answer

AHDI recommends transcribing 'status post' in full rather than using the s/p abbreviation unless the facility style guide specifies otherwise.

Question 5

In an emergency department report, the 'EMERGENCY DEPARTMENT COURSE' section is analogous to which section in a discharge summary?

Accepted Answer

Hospital Course

Answer

The ED Course describes the sequence of events during the ED visit, just as Hospital Course narrates the patient's inpatient stay.

(MT) Certified Medical Transcription Practice Test