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jso,rn09 Page 1
Four spaces between
last
Paragraph and signature
rule
Name of Doctor
Double space from
signature block to
SB:xx dictator/ transcriptionist
initials
D: 12/01/2009
Format dates as
MM/DD/YYYY
T: 12/01/2009
CC:
RADIOLOGY REPORT
RADIOLOGY REPORT
Patient Name:
Hospital No.:
X-ray No.:
Admitting Physician:
Procedure:
Date:
PRIMARY DIAGNOSIS
CLINICAL INFORMATION
IMPRESSION
Side Note:
Roentgenography – making
records of the internal
structure of the body.
jso,rn09 Page 2
OPERATIVE REPORT
Patient Name:
Hospital No.:
Date of Surgery:
Admitting Physician:
Surgeons:
Preoperative Diagnosis:
Postoperative Diagnosis:
Operative Procedure:
Anesthesia:
DESCRIPTION:
PATHOLOGY REPORT
Patient Name:
Hospital No.:
Pathology Report No.:
Admitting Physician:
Preoperative Diagnosis:
Postoperative Diagnosis:
Specimen Submitted:
Date Received:
Date Reported:
GROSS DESCRIPTION:
GROSS DIAGNOSIS:
MICROSCOPIC DIAGNOSIS:
Patient Name:
Hospital No.:
Consultant:
Requesting Physician:
Date:
Reason for Consultation:
BURNING AGENT: *Example
TREATMENT PLAN
GOALS
jso,rn09 Page 3
DISCHARGE SUMMARY (Final Progress Note or
Clinical Resume)
Patient Name:
Hospital No.:
Admitted:
Discharged:
Consultations:
Procedures:
Complications:
Admitting Diagnosis:
HISTORY:
DIAGNOSTIC DATA ON ADMISSION:
HOSPITAL COURSE:
DISCHARGE SUMMARY:
DEATH SUMMARY
Patient Name:
Hospital No.:
Admitted:
Deceased:
Consultations:
Procedures:
ADMITTING DIAGNOSES
FINAL DIAGNOSES
COURSE IN HOSPITAL:
DIAGNOSTIC DATA:
CAUSE OF DEATH
Patient Name:
PCP:
Date of Birth:
Sex:
Date of Exam:
HISTORY:
PHYSICAL EXAMINATION: (HEENT, NECK, CHEST, SKIN,
ABDOMEN, EXTREMETIES)
IMPRESSION:
PLAN:
jso,rn09 Page 4
AUTOPSY REPORT
Patient Name:
Hospital No.:
Necropsy No.:
Admitting Physician:
Pathologist:
Date of Death:
Date of Autopsy:
Admitting Diagnosis:
Prosector:
jso,rn09 Page 5
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN
Date of Exam:
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
CORRESPONDENCE/LETTER
Date
Sincerely,
SCG: xx
jso,rn09 Page 6