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 Note

Can 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