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How to Write a Medical Report

The Importance Of A Well Written Medical Report.

How to write a medical report would usually be perceived as a question relevant to only freshmen and junior or novice healthcare professionals. In reality, it is a concern even for the most senior and experienced professionals. This is because medical reports are very important documents. They may be used in court cases, to approve the payment of disability pensions and benefits, to provide healthcare services and in many other decision making situations. Therefore, medical reports come under great scrutiny and the quality of writing reflects on the writer. It is pertinent to note that writing a medical report and a well written medical report are as different as night and day.

How Should The Report Be Written?

It would help if the subject is treated part by part.

  1. What is the patient’s story on their medical condition? Listen, record and refer to your notes when writing the report. There are many instances where details are far different from what was given by the patient. Add what your senses of sight and hearing tell you based on your observation of the patient. Please do not refer to the patient as a subject. Use their names as often as you can.
  2. Write an assessment based on your examination and assessment of the condition. Record all the facts correctly. What conclusions have you arrived at? Consider the legal and other implications of your report.
  3. What are the options in terms of treatment, medications, therapies, further tests, examination and consultation? Consider this as a whole approach towards the patient’s healthcare. What are your specific and general recommendations?
  4. Mark out any mistakes made when writing the report with a single line across a word or sentence. Do not try to camouflage errors. Acknowledge errors with your initials next to it.

Additional Suggestions

When writing your report, think of the target audience. Use plain language. Avoid difficult medical terms and jargon. If they have to be used, briefly explain their meaning in lay terms. Keep your sentences short and simple. Check details. Check your facts. If you are writing a long report, break it up into parts with suitable headings. As a medical report is a highly confidential and private document, getting it checked by a third party is not advisable. Using software to edit the document would be a better option. To enable you to write better medical reports and do it easily, there is a special version medical writing that is now available.


Source by Azhar Devaraj Victor


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