History and Physical Dictation

Code 03

Make sure to spell names and guide the transcriber about format.

Your Name

Patient's Name

Medical Record #

Date of Birth

Admission Date

Chief Complaint

History of Present Illness (HPI)

Past Medical History with dates (PMHx)

Past Surgical History (PSHx)

Medications

Allergies

Social History

Family History

Review of Symptoms

Vital Signs on presentation

Physical Exam

Labs

Studies

Assessment and Plan in order of importance

State the Residents/Doctors who saw the patient and/or were available. 

Discharge Summary Dictation

(Code: 06)

Remember: No discharge dictation required of stays < 48 hours.

Your Name

Patient's Name

Medical Record #

Date of Birth

Admission Date & Discharge Date

Admission Diagnosis(es) & Discharge Diagnosis(es)

Brief Admission History

Hospital Course

Pertinent Labs

Studies

Procedures

Consultations

Discharge Medications

Disposition