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Medical Report Format

Hospital/Clinic Name Address City, State, ZIP Code


Patient Name: Patient ID: Date of Birth:

Subject: Medical Report for [Patient Name]

1. Introduction

2. Patient Information

3. Medical History

4. Examination Findings

5. Diagnostic Tests

6. Diagnosis

7. Treatment Plan

8. Prognosis

9. Conclusion

Physician’s Signature:

[Physician’s Name] [Physician’s Title] [Department]

Medical Report Samples

What is Medical Report?

A Medical Report is a detailed document that records the medical history, diagnosis, treatment, and progress of a patient. It is used by healthcare providers to track patient care and by patients to understand their medical condition. A Medical Report is essential for accurate medical documentation, facilitating communication among healthcare professionals, and ensuring continuity of care. This report often includes detailed notes on patient symptoms, diagnostic tests, treatment plans, and follow-up care.

According to Statista’s September 2021 research survey, there were over 1,062,205 professionally active physicians in America.

Why Are Medical Reports Important?

You can already assume that a medical report is important because it tracks your health condition. But it actually has more advantages than that. And here are some reasons that prove just how essential medical reports are:

Life Is on the Line

A medical or health report is the easiest way to communicate about a person’s medical condition or health in the most detailed approach. So rather than just assuming someone is healthy with no medical checkups, a medical report is much more credible because medical professionals are the ones assessing patients. And you deserve to know if you need a new diagnosis, have a chance to develop cancer, or any crucial factor to make sure you are living in the healthiest way possible.

Benefits Both Patients and Health Professionals

Not only are the patients concerned about their current health condition because even medical professionals want to know more about their patients’ health. That way, experts can provide the correct treatment or diagnosis for patients. With that said, the medical expert can learn something about the patient and the patient would learn something from the professional. A medical report is beneficial for both parties until they can set an contract and agreement on how to improve the patient’s life.

Flexible for Different Purposes

Why is a medical report needed in the first place? There are various reasons why it is necessary. A common example is when a clinical report is a requirement for employment. Employers would want to know ahead if their employees are fit to work, especially if the job is demanding. Also, a student who spent days or weeks in a hospital can submit a medical report in class to testify what happened on those days the student was absent for a long time. Another purpose is when a patient asks for a new surgery and the medical report is initiated ahead to prove if the patient is even healthy enough to go through that surgery. Nonetheless, it is vital for medical reports to contain data that support their purpose.

Solid Evidence

Medical reports work as solid proof such as when medical professionals head to court for medical negligence. The report they made can prove or disprove whether they gathered the appropriate client information sheet in terms of health or not. And one factor that makes the report form credible is how a team of licensed professionals are the ones assessing a patient’s medical condition. You can certainly rely on the findings from healthcare experts rather than just using medical forms with no credible source.

Up-to-Date Information

Also an extremely notable reason why medical reports are vital is how their information is updated regularly. The medical report even includes a date segment to confirm how new or old the report is. In a year, a person’s health condition could change rapidly so it only makes sense for medical reports to have up-to-date information. Changes could be related to the patient’s medical progress, prescription, or address, perhaps. And that explains why seeing doctors regularly is needed too, especially when no health is permanent.

Standard Instruments of a Medical Report

If medical professionals have their own set of medical instruments and equipment to work completely, then medical reports also have their own set of instruments to make sure the report covers the complete details. Albeit medical reports have varying content from one example to another, it is likely that the average medical report contains the following basic components:

Patient Information: The patient information is the basic information in the medical report. It tackles the patient’s name, address, and contact list. But, it also mentions the summary of the patient’s condition, the purpose of the medical report, and the date of the report. This part introduces what the medical report will be talking about.Medical History: The patient’s medical history will be presented in an easy-to-read executive summary. This overview will cover the remarks made by medical experts and a timeline of how the patient’s medical condition went from old data to the most current one.Hospital Discharge Summary: Another standard summary is the hospital discharge summary. Generally, it marks the date of when the patient checked out from a hospital. But, it also includes the reason why the patient got hospitalized in the first place, its related test results, and how the patient felt once discharged for follow-ups.Physical and Mental Examination: A medical report would not be complete without the medical examination details. It is often divided according to the physical and the mental examination. And this examination is crucial in providing whether the patient is fit to work or mentally capable to do so.Laboratory Test Results: Whether there was a blood test, heart test, urine test, or any other laboratory test, its results should be mentioned in the medical report. Just like a test report, the results matter as they say a lot whether the patient is healthy or unhealthy. Also, the answers must be translated into layman’s terms, especially if they are hard to read.Medical Images: Medical images are possible attachments to your medical report. X-rays and other photographic results about a patient’s medical condition will be attached as the medical report’s supporting evidence.Diagnosis Documentation: Document the data of the treatments and diagnosis given to the patient. This is preferable for patients who have previous medical conditions already. So what medicines or diagnoses they took will be crucial for medical records.Response to Treatments: With the diagnosis or treatments given, how did the patient respond? Even though a certain medicine or treatment is expected to heal patients, there are times when the results don’t go according to plan. Bodies differ in health anyway so how bodies respond to treatments can have varying results. And a timeline chart documenting those responses will be helpful to the report.Confirmation Statement: Lastly, insert the confirmation statement of the patient’s medical condition in the report. This part is what concerns most people because even though there are histories, test results, and important data in the medical report, the confirmation statement is the final evaluation of whether someone is healthy or unhealthy. And the answer should be signed by the health professional to validate it.

How to Make a Stellar Medical Report

Making a medical report may be challenging but it is doable when you are guided by a series of steps. And these are the only steps you need to follow to create the best medical report possible:

  • Step 1: Identify the Purpose of Making the Medical Report

    Remember that how much data to add to the medical report depends on the purpose behind making one. So be sure to set your statement of purpose whether you need the medical report for medical research, medical education, health insurance or compensation, medical malpractice lawsuit, medical audit, or simply a general patient monitoring report. Because imagine if you apply for health insurance yet no background information about the client’s medical history was given. How would you know that you applied for the appropriate health services that align with your condition? Hence, prepare medical reports according to purpose.

  • Step 2: Download a Sample Medical Report Template

    Refrain from making medical reports from scratch because it will only give you a time-consuming process. Instead, use our 36+ sample medical reports for your reference. You can choose from a confidential medical report, driving license medical report, medical insurance report, annual medical report form, medical fitness assessment report, health assessment report, and lots more. Once you select a template to download, you can even edit the content until it is fully personalized according to your preferences. Expect to add the full details that complete a medical report afterward.

  • Step 3: Provide the General Background Information

    Personalize your medical report starting with its background information. This portion serves as the introductory statement of the medical report. From the date, time, venue, and reason of assessment, label the background of your medical report promptly. The terms, agreement, and sources of the medical report will be incorporated here too. What matters the most is that the background information provides enough insight into what the gist of the medical report is.

  • Step 4: Insert the Appropriate Medical Report Components

    As previously discussed about the medical report components, be sure you have the standard components that make up a proper medical report. From patient information down to the confirmation statement, such components will surely make your report a detailed report. You may insert more components to expound the report as well. However, make sure that the data you add are specific and easy to understand. It is a common mistake by doctors to use technical words and medical terms on a daily basis but the general public may not understand what those words mean. Most importantly, organize your sentences as those may be responsible for making the report hard to follow.

  • Step 5: End with the Official Management Statement

    The perfect closing statement of a medical report is the official statement from the management. Medical professionals must confirm that under specific investigations and measures, the patient is actually healthy or not. Statements would confirm the patient’s abilities and limitations. Comments and remarks from these experts will be welcome too. And if there is an ongoing treatment or medication to be taken, that means additional medical reports will be needed in the long run. Nonetheless, practice medical reporting regularly to stay wholly aware of one’s health condition.

How many professional physicians are in the US?

As of September 2021, America has over 1,062, 205 professionally activity physicians. With that big number, it is no excuse that you cannot find an expert to help you process a medical report.

What are examples of medical records?

A medical report is just one example of a medical record. Other notable examples of medical records are the patient information leaflet, medical history record, operative report, hospital discharge summary, mental status examination, physical status examination, and a medical test. You should also take a look at our Medical Business Proposal

How can I get a medical report?

To get a medical report, you simply need to fill out a request form specifically for requesting medical records. You can submit the form to the doctor or the hospital that has your report. And it can be sent to you via print or email. But if there is no request form provided, just write a request letter instead. You should also take a look at our Child Medical Consent

How to Check Online Medical Report?


Checking an online Medical Report involves accessing your healthcare provider’s digital system and ensuring secure login. Key steps include:

Why Do I Need a Medical Report?

A Medical Report is crucial for tracking health status, managing medical conditions, and ensuring continuity of care. Key reasons include:

What Happens in a Medical Report?

A Medical Report documents a patient’s medical history, diagnosis, treatment, and progress. Key components include:

What Are 5 Reasons Medical Records Are Kept?

Medical records are essential for various healthcare and administrative purposes. Key reasons include:

What Is Included in a Medical Incident Report?


A Medical Incident Report details any unexpected events affecting patient care. Key elements include:

What is the Medical Check Up for Visa?

A visa medical check-up includes a physical examination, chest X-ray, and blood tests to ensure the applicant meets health standards, documented in a Medical Case Summary.

What Blood Test is Required for I-693?

The I-693 form requires blood tests for communicable diseases such as syphilis and tuberculosis, recorded as part of the Medical Release Form.

What is the App for Medical Report Record?

An app like MyChart allows you to securely access and manage your Medical Project Proposal and other health records online.

How Can I Find Accurate Medical Information Online?

To find accurate medical information, use trusted sources like Mayo Clinic or WebMD, ensuring you cross-check with official Medical Questionnaires.

How Do I Check My Medical Fitness Report?

Check your medical fitness report by logging into your healthcare provider’s portal and navigating to the Medical Records Release section.

What is Included in a Patient Report?

A Patient Medical Report includes patient information, medical history, diagnosis, treatment, and progress notes, forming a comprehensive health overview.

How to Download a Medical Report Online?

To download a medical report online, log into your healthcare provider’s portal, select the Medical / Health Invoice section, and download the desired report.

In conclusion, mastering the creation of a Medical Report is crucial for accurate and effective medical documentation. With our guide, you have learned how to draft detailed samples, forms, and letters, ensuring your reports are comprehensive and precise. Utilizing the provided templates and tips, you can streamline your documentation process and enhance the quality of your medical records. For more detailed examples and templates, visit Medical (Health Care) Power of Attorney Form.