Psychiatry Consultation Report - momof3

Posted: Oct 12, 2009

working on a psychiatry consulation report and there are only a few headings dictated. "History of Present Illness", "Review of Past Medical Records", "Developmental Background", and "Diagnosis". Under "Review of Past Medical Records" there are several paragraphs dictated without headings and each one starts out with "Doctor (doctors name is cut off) diagnosed (or indicates) etc....., examples: Doctor diagnosed head injury, loss of consciousness, bilateral clavicle fractures, right scapular fracture, right humeral neck fracture, depressed left tibial plateau fracture, and pelvis fracture. Doctor indicated electromyogram(EMG)nerve conduction showed neuropraxic injuries to the peroneal nerve, and posterior tibial. Doctor diagnosed status post percutaneous transluminal coronary angiography, steroid dependant asthma, hypertension, arrhythmias, and depression. Doctor diagnosed left arm and left leg incoordination and weakness, with significant limitation in her distance of ambulation and manipulation of her left arm, back pain and spasms, healed multiple fractures from injury of August, history of cataracts and eye surgery, asthma, and chromic obstructive pulmonary disease with steroid dependency and multiple steroid side effects. Doctor diagnosed low average to average intellectual functioning with very mild brain damage affecting functioning. This goes on for about 8 paragraphs. Should there be heading above each one or should each paragraph be transcribed as above?