Dictation Format

History and Physical             Operative Report               Discharge Summary 

HISTORY AND PHYSICAL
Patient Name
Medical Record Number
Admission Date
Chief Complaint
Details of Present Illness
Past Medical History
Family History
Social History 

Inventory of Body Systems
          Respiratory
          Cardiovascular
          GI
          GU
          Musculoskeletal
          Neurological

Physical Examination
          Vital signs
          General
          HEENT
          Neck
          Chest
          Heart
          Abdomen
          Rectal
          Genitalia
          Extremities
          Neurological 

Impression
Plan 

OPERATIVE REPORT
Patient name (Must be spelled out)
Medical Record number
Date of operation
Pre-operative diagnosis
Post-operative diagnosis
Name of operation
Anesthesia
Primary surgeon
Assistants
Pathological findings
Specimens removed
Estimated blood loss
Description of the procedure 

The completed operative report should be authenticated by the surgeon and filed in the HISS Department as soon as possible after surgery.  There should be comprehensive operative progress note entered in the medical record immediately after surgery, in order to provide pertinent information for use by any practitioner who is required to attend the patient.  

DISCHARGE SUMMARY
Patient name
Medical record number
Admitting date
Discharge date
Discharge diagnosis
Procedures performed
Hospital course
Significant findings
Laboratory Data
Condition on discharge
Instructions regarding physical activity, medications and diet
Follow-up care