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Example of a Document
Template and Dictation Template
Doctor's
name: [transcribe as
dictated] Doctor's ID: [transcribe as dictated] Patient ID: [transcribe as
dictated] Subject: [transcribe as dictated] Reason for Consultation: [transcribe as dictated] History of Present Illness: [transcribe as dictated] Past Medical History: [transcribe as
dictated] |
Allergies:
[transcribe as dictated] Physical examination: [doctor will indicate
template]
xxxxx xxxxxxx xxxxxxxx xxxxxx xxxxxx x xxxx xxxxx x xxxxxx xxxxxx xxxxx xxxx xxxx xxxx xxxx xxxxxxx xxxxx
Problem List: [transcribe as dictated] Recommendations: [transcribe as
dictated]
Followup: [transcribe as dictated]
Legend:
Code: Document template: Red
Dictation template: Blue.
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