medical letters &medical reports
an enclosure includes
origional claim form, copy of denial, EOB & other supporting documents.
letter of medical necessity must include
patients name, DOB, ID#, policy#, or group#.
workers compensation reports include what 7 things
-Hx of present illness -past medical history -allergies -medications -family medical history -ROS -MD impressions
an operative report details
-Why the Sx was done -What the surgeon discovered during the procedure. -The final diagnosis.
the autopsy report includes 7 various headings
-external exam -internal exam -body systems -dissections -microscopic exam -cause of death -comments
medical reports
Are documents that describe and encounter between health care provider and patient. These legal documents that become a part pf the pts medical record.
letter of medical necessity ar usually written to a
contact person
thank you for referral letters include
pt name, age, gender, race, symptoms, and plan of Tx
thank you for referral letters
this letter is sent to the referring doctor by the physician (usually a specialist) to thank him/her for referring the patient.
letter of medical necessity
this type of letter informs and persuades the patinets health insurance to pay for a procedure, medication or treatment that is not covered.
three parts of "normal test letters" to patients
what test was done. when was test taken. how long before the next appointment.
5 parts of "abnormal test result"
what test was taken when was test taken what are the consequences of an abnormal result should patient be worried how long before next appointment
consultation report
when a physician consults whit another to manage a pts care.
4 parts of a radiology report
-xrays -Ct scans -MRI -nuclear medicine and other floroscopic exams
10 examples of medical reports are
1. history and physical exam 2. operative report 3. pathology report 4.consultation report 5. discharge summary 6. discharge instructions 7. autopsy report 8. radiology report 9. SOAP notes/chart (progress notes) 10. workers compensation
the body of a medical letter includes
Brief patient history & Dx. Brief description of the patients symptom. The therapy to date that has not worked. Benefits of the new procedure, meds or treatment. Enclosure.
at the bottom of medical reports the notations( D) &(T) mean?
D=date of dictation T=date of transcription
discharge summary
Explains why the pt was admited. Includes review on what occured during the pts hospital stay. discharge diagnosis and pts condition on leaving the hospital is noted.
what 4 reports contain ROS
Hx and physical , workers comp, cosultation, autopsy.
"letters of referral' to another M.D. include
Introduction written by a doctor to another doctor requesting that he/she see the patient.
5 parts of a "missed appointment letter"
Is there a penalty ( if so when it will apply. Date of missed appointment. What procedure was planned. How quickly should pt reschedule. Is this habitual?
3 types of letters sent to other Dr or health insurance companies
Letters of refferal to another MD. Thank you for referral letters. Letters of medical necessity.
6 letters to patients
Normal test results. Abnormal test result. Collection letter. Dismissal letter. Missed appointment letter. How long befor next appointment.
reasons for dismissal
Not taking meds. Not taking care of them selves. Cancelling or missing appointment. Unruly patient. Disruptive. Nonpayment. Hypochondriac. Theft. People selling drugs.
The 5 things that history of a physical exam report includes are
Pts cc, past medical history, family medical history, social history, ROS
2 reasons for reffering a patient would include
Pts condition requires that they been seen by a specialist. Referring doctor may want a second opinion.
5 things included in a "dismissal letter"
Reasons for dismissal. What type of care patient was getting. What can patient do to remain you patient. Offer referral to another provider. Mention that doctorwill continue to see pt for the next 30 days from date of letter.
SOAP stands for
S=subjective- what pt is complaining about O=objective-clinical evidence (Ht,Wt,Bp,ect....) A=assessment=doctors assessment or diagnosis P=plan=how doctor will manage the pts care.
2 things that the physical exam portion of the history and physical exam report which consists of the doctors observations are
The doctors overall impression and diagnosis. Concludes with a plan of treatment if any.
chart notes
a providers formal or informal notes about presenting problem, physical findings and plan for treatment.Written by MD or other medical personnel
12 parts of a "collection letter"
amount due how long over due how many other letters have been sent date of service which doctor was seen what procedure was done when is payment required buy what will happen if payment is not made offer a payment plan insurance information include phone # include office hrs
autopsy report
an autopsy is done to discover the cause of death
discharge instructions
are for patients who have received treatment or have undergone a procedure.
next appointment letter
how long before next appointment
a consultation report is a letter of
introduction which includes a brief explination of tests and results already performed.
pathology report
is generated by the pathologist as a result of examining the tissue and organs removed during a surgical procedure (biopsy) or autopsy
operative report
is produced on all pts whe have had a surgical procedure.
pathology
is the branch of medicine that studies the causes of disease and the outcome of the specimen.
workers compensation
medical insurance for workers who have sustained an injury at the work place.
