According to the RMT Content page on AHDI’s website, the report types covered are: H&Ps, Consultations, Operation/Procedure Notes, Discharge Summaries, Radiology Reports, Pathology Reports, Clinic Notes, Letters, and Progress Reports. Format styles and structure are not covered. Yay for that!

Is a Clinic Note the same as a Chart Note?Types of reports and typical topics included as per the BOS 3rd edition…

Consultation Report:A consultation includes examination, review, and assessment of a patient by a healthcare provider other than the attending physician. The history and physical sections are repetitive of information in the original H&P. Unique content topics found in a consultation report/letter include:

Diagnostic Studies Assessment, Diagnosis, or Differential Diagnosis Recommendation or Plan

Correspondence or Letters Discharge Summary:

Admitting Diagnosis Discharge Diagnosis Chief Complaint History or History of Present Illness Hospital Course Prognosis Plan, Discharge Plan, or Disposition Discharge Instructions Condition

History and Physical Examination:The foundational document of the clinical record, upon which all other documentation for a patient is built. It is required to be in the record before anything other than emergent treatment can be provided.

Chief Complaint History of Present Illness Past History Allergies Current Medications Review of Systems Physical Examination Mental Status Examination Diagnostic Studies Diagnosis Orders

Operative Report: Preoperative Diagnosis Postoperative Diagnosis Reason for Operation or Indications Operation Performed or Name of Operation Surgeon Assistants Anesthesiologist

Anesthesia Indications for Procedure Findings Procedure, Operative Course, or Technique Complications Tourniquet Time Hardware Drains Specimens Estimated Blood Loss Instrument, Sponge, and Needle Counts Disposition of Patient Followup

Pathology Report:Any specimen sent for a pathologic evaluation will undergo two distinct evaluations by the pathologist – gross and microscopic. These can be dictated either separately or together.

Specimen Clinical Data or Clinical History Gross or Gross description Microscopic or Microscopic Description Diagnosis or Microscopic Diagnosis

Progress Note or Followup NoteCan be either a simple narrative or in SOAP format. Unless using SOAP format, they have no standardized or common headings or subheadings.

SOAP Note Subjective (history) Objective (physical exam) Assessment (diagnosis) Plan

Radiology Report (please verify) Findings Impression