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With this report, we can analyze what we are going through. We can read it through a patient medical report form or patient medical report letter. The report has the diagnosis about us whether we are diagnosed with cancer, malaria, diabetes, or stroke. It can be used for many purposes like it can be used as a medical proof for work in times of leave because of our sickness. Our sickness should be documented because it can help us to see what we should do to cope up with the disease. If you want to learn the things about a patient medical report, you can keep on reading this article, so you will be informed of the importance of a patient medical report. You can also learn how to write a patient medical report. The things that you should include in a patient medical report are also tackled in this artcle. Enjoy the reading!
3+ Sample Patient Medical Report
What is a Patient Medical Report?
A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has. It has the complete diagnosis on the patient, clearly stating the disease that should be treated. Through a patient medical report, anyone can analyze the health condition of a person. It sometimes contain a patient chart where the demographic profile of the patient is introduced. All types of medical records need a medical report. Patient medical records are simple data about the patient while a patient medical report is more elaborate and comprehensive. Though the importance of medical records and the purpose of medical records are almost the same with a patient medical report, the patient medical report is more beneficial. It has a complete summary of the diagnosis on the patient and have some recommendations for the health of the patient.
What You Should Include in a Patient Medical Report
A patient medical report has some important elements that you should not forget. Include all these things and you can learn how to write a patient medical report.
On top of everything, you must include the personal information of the person. Write the patient’s name correctly. Include the patient’s age, city, sex, height, weight, and other important details. The pesonal data should be given so the patient medical report can be easily found in case it will be mixed with other files.
Ask the patient about his medical history. You should put it to have a better analyzation of the medical condition of the patient. It can also make the doctors to be careful with the medication that they can give to the patient. Whatever is the sickness that a patient has before he is admitted to the hospital should be written in the patient medical report.
Diagnosis on the Patient
One thing that a doctor should have documented in the patient medical report is the medical diagnosis that he has found in the patient. Whatever disease that a patient has should be clearly stated in the medical report. The name of the disease should be clearly written and some explanations about the current condition of the patient.
Treatments or Medications
Whatever medicine that has been prescribed to the patient should be included in the patient medical report. The treatments or medications should also be documented because it can provide a good information about the medical history of a patient. Put the names of the medicines and tell how often did the patient takes it. You can also document its effect and tell whether it is effective for them.
Physical and Mental Findings
The result of physical examinations and mental examinations should also be stated in the patient medical report. It can tell the whole condition of the patient. The physical and mental findings will tell whether the patient would be fit for all the medications. Not all medical record documentation has this, but it is better if you will include this.
All laboratory results and tests like X-ray should also be included in the patient medical report. It can provide a good observation for the health condition of the patient. It is also needed because sometimes the laboratory and the test results are the proof of the sickness of the patient. For example, if the patient has a blood cancer, it can be seen with the blood tests. If the patient has a brain tumor, it can be seen through a brain CT scan. A CT scan for the body can also tell whether we have a fracture or not.
Limitation and Ability Statements
These are statements about the recommendations of the doctor. They are statements whether a patient can do a particular thing or not. It tell limitations on thing that they should not do for a while and it tell the abilities that they, of course, have. This is necessary so that the sickness will not get worse.
Importance of a Patient Medical Report
The reason why a patient medical report is always given is because it is important. Here, you can know some of the importance of a patient medical report:
How to Write a Good Patient Medical Report
A doctor is a doctor. They are not writers. They can be caught in a difficulty on how to write a patient medical report. If this is the case, turn to this article and use these steps in making a patient medical report.
Step 1: Create an introduction about the background.
Have an abstract about the patient medical report. Make an introduction about it. Data like the date and the reason of examination should be included. Describe how you are involved in the case. Use quote verbatim on critical issues. Tackle the abstract in 2-3 paragraphs. This should be a good introduction to the patient medical report. It can prepare the readers to whatever medical report that you can be somehow announcing.
Step 2: Write the medical history of the patient.
Before you will deliver your observations for the patient, you must first tackle about his medical history. This is necessary to avoid wrong recommendations and to explain the health condition of the patient better. The medical history should include history of allergies, history of times that the patient was admitted in a hospital, and history of medications that the patient has taken in the past years. Have a brief but complete description of the patient’s medical history.
Step 3: Report the specimens.
Whatever test and examination that you have given to the patient, have the result documented. These will be the laboratory results and test results to have an analysis of what disease could have touched the patient. There should be a clear notation how you have derived the specimens. Comments on tests are important and can also be included in the patient medical report.
Step 4: Be clear about the diagnosis.
The main point of the patient medical report is the diagnosis that you have for the patient. Whatever disease you have detected on the patient, you must clearly state it in the medical report. Put a proper description about the disease. Tell whether it is in a starting stage or whether it is in the worst case. Be sure about your diagnosis because the patient is surely counting on it.
Step 5: Give your opinion as a health care provider.
At the last part of the medical report, state your professional opinion about your diagnosis. You can elaborate the description that you had with the diagnosis. After explaining the course of the disease, you can have some recommendations that you can advise to the patient. This will tell the patient what to do to treat the disease. It can give hope to the patient that the disease is curable. End your report with a good comment that will summarize the patient’s health condition and will provide solution to the patient’s problem. After that, you can let any reader to read your patient medical report.
Who Writes the Patient Medical Report?
Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physicians, nurses, and doctors of medicine. It also includes the psychiatrists, pharmacists, midwives and other employees in the allied health. It is part of their job to make a patient medical report because the health condition of all the patients should be documented. Hospitals keep history of medical records. The functions of medical records are more than important, so they continually keep track on the patient’s health conditions.
Who Can Have Access to a Patient Medical Report?
The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patients’ access to the patient medical report is a must. It is their right to see their medical report. It is against the law not to show them their medical report. It can be a proof if there is any doctor withholding treatments. So, to avoid conflict, the patient medical report should be shown to the patients. HIPAA (Health Insurance Portability and Accountability Act) has been passed in the Congress of United States. Passed in 1996, it specifies who can have an access to all the health information. You can research for that law, so you can have the exact details to who can have an access to a patient medical report. It is better because you can have a legal source. It can tell you all the things that you need to know about it.
Is a Patient Medical Report a Legal Document?
If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patient is under your care. Thus, it can be used in court as an essential proof. So, keep a patient medical report because you may need it in the future.
If ever you are admitted in a hospital, you must request to have your patient medical report. It will inform you about your current situation. On the other hand, are you a health care provider? Is it your first time to make a patient medical report? You can use any of the downloadable templates in this post. They can help you how to write a patient medical report. You must remember that you should be careful in writing a patient medical report. You have to give your best in writing it. Use these templates and it can help you a lot.