D.3 SAMPLE REPORT FORMATS.pdf
PDF 91 KB Posted
- Attached to
- Medical Transcription Services Federal contract opportunity
- Solicitation number
- 36C25724Q0480
About this file
This document appears to be a sample medical report format, containing templates for a Discharge Summary, History and Physical, and Mental Health History. It does not contain any specific details about a federal contract opportunity. The sample reports provide standard formats and required information for documenting patient medical history, physical examination, diagnoses, treatment, and disposition. However, this document does not describe the products, services, requirements, or other details related to the federal contract opportunity referenced. The attached federal contract opportunity solicitation is for Medical Transcription Services, issued by the Department of Veterans Affairs.
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| File | Type | Posted |
|---|---|---|
| D.1 P07_WAGE DETERMINATION 2015-5227.pdf | ||
| D.2 BUSINESS ASSOCIATE AGREEMENT.docx | DOCX document | |
| S02_RFQ 36C25724Q0480-Transcription v4.docx | DOCX document |
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SAMPLE REPORT: DISCHARGE SUMMARY STAT DISCHARGE SUMMARY
DATE OF ADMISSION
DATE OF DISCHARGE
ADMITTING/DISCHARGE DIAGNOSES
OPERATIONS/PROCEDURES/CONSULTATIONS
HISTORY OF PRESENT ILLNESS
PHYSICAL EXAMINATION
LABORATORY DATA
HOSPITAL COURSE
DISCHARGE MEDICATIONS
DISPOSITION
PATIENT EDUCATION
The patient was informed of his/her diagnosis/condition and treatment plan was discussed. The patient's level of understanding was ///.
SAMPLE REPORT: HISTORY AND PHYSICAL
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
MEDICATIONS
ALLERGIES
SOCIAL HISTORY
FAMILY HISTORY
PHYSICAL EXAMINATION
VITALS: ///
GENERAL: ///
HEENT: ///
NECK: ///
LUNGS: ///
CARDIOVASCULAR: ///
ABDOMEN: ///
BACK: ///
PELVIS: ///
EXTREMITIES: ///
RECTAL: ///
NEURO: ///
LABORATORY DATA
CHEST X-RAY
EKG
ASSESSMENT
PLAN
SAMPLE REPORT: MH HISTORY
DATE OF EXAMINATION
PRESENTING CHIEF COMPLAINT
HISTORY OF CURRENT ILLNESS
PAST PSYCHIATRIC HISTORY
CONTACT WITH PREVIOUS MENTAL HEALTH PROVIDERS
RECORD REVIEW
I have reviewed the remote records and current chart.
The information is consistent with patient report.
HISTORY OF SUICIDAL ACTS AND SELF HARM
HISTORY OF VIOLENCE
SUBSTANCE ABUSE HISTORY
FAMILY MENTAL HEALTH AND SUBSTANCE ABUSE HISTORY
SOCIAL HISTORY
MILITARY HISTORY
PTSD SCREENING
MEDICAL/SURGICAL HISTORY
CURRENT VA PRESCRIBED MEDICATIONS
CURRENT NON-VA MEDICATIONS
Medications above have been reviewed and reconciled to reflect an accurate home list.
ALLERGIES
MEDICAL REVIEW OF SYSTEMS
SUICIDE RISK ASSESSMENT
MENTAL STATUS EXAMINATION
INITIAL DSM-IV DIAGNOSES
AXIS I ///
AXIS II ///
AXIS III ///
AXIS IV ///
AXIS V ///
INITIAL IMPRESSION AND BIOPSYCHOSOCIAL FORMULATION
PRELIMINARY PROBLEM LIST
PRELIMINARY PLAN OF CARE
MEDICATIONS
The patient understands he can contact the clinic during working hours if problems arise. Off hours he can contact the VA and speak with a psychiatrist on call. The patient was given the number to the National Suicide Hot Line. In case of an emergency he knows to call 911, go to the nearest emergency room or come directly to the VA.
SAMPLE REPORT: MH HISTORY
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