Medical Reports

Dr. Nasser Al - Jarallah

Medical Reports•There are many different types of medical reports, written for different reasons.

•If you work in the healthcare industry, you must often write medical reports.

- Medical History- Physical

Examination- Physician Orders- Progress Notes- Laboratory

Reports

- Radiology Reports- Other Diagnostic

Procedures- Medication Sheet- Consent Forms- Consultation

Reports

Medical Reports

Medical Reports•You also may need to know how to write a medical report if you care for a sick person in the home.

•The information in the report must be timely and confidential so that it can serve as a legal document if necessary

Medical Reports•Step1

▫ Know that a common type of medical report is written using the SOAP method. This stands for Subjective Objective Assessment Plan.

▫ The subjective part of the report tells what the patient says about his symptoms in his own words.

▫ The objective part of the report details what you see and hear when you observe the patient.

Medical Reports•Step2

▫ Assess the patient after observing his problems and symptoms. When you write a medical report, this is where the analysis of the condition is noted.

▫ Tell what conclusions can be drawn to assist the diagnosis.

▫ Document all the facts accurately and concisely.

Medical Reports

•Step3▫Write the Plan part of the medical report.

▫The plan includes the overall treatment, any medications used and any other therapies involved in caring for the patient.

Medical Reports•Step4

▫ Note any problems when you write a medical report.

▫ Write the date and time beside each entry.▫ Enter medications or treatments as given.▫ When you are writing a medical report

using the focus charting method, use dark ink and write legibly.

▫ Never skip lines when writing a medical report.

Medical Reports

•Step5▫Draw a single line through any

error you make when you're writing a medical report.

▫Never erase or white out an entry. ▫This is particularly important for

legal reasons. ▫Put your initials beside the error

line. 

CONFIDENTIALITY

•Confidentiality and privacy are terms often used interchangeably in reference to medical data .

•Privacy is the right to be left alone.•Confidentiality means keeping secret.•Medical Confidentiality is concerned with the restrictive use of information obtained from and about a patient.

CONFIDENTIALITYCONSENT TO RELEASING INFORMATION

▫Informed consent means that the patient is aware, in a general way, what information will be released and use that will be made of the information

▫Written authorization of releasing information

▫Policies and procedures of releasing information

CONFIDENTIALITY

Methods of Releasing Information - Direct access- Abstracting Information- Oral release- Photocopying- Fax Transmission- Mail

Medical Progress Report•The purpose of a medical progress report is to provide better patient care, as

•it gives members of a healthcare team the opportunity to note their observations as to a patient's condition, including any adverse effects of medication.

Medical Progress Report•In most cases, progress notes are recorded daily.

•Progress notes are an important tool for communicating facts about a patient's condition,

•however, the information should be organized in such a way that others can easily follow the patient's progress.

Medical Progress ReportStep1• Identify the patient by indicating his or her

demographics at the top of the page. The patient's name, chart number, address, home telephone number, sex, National I.D number and date of birth are usually listed.

• Some reports include the patient's occupation, work telephone number and the name of the guarantor as well.

• The patient's height, weight and race may also be included.

Medical Progress ReportStep2•Include the date of the report in addition

to the names and initials of any people making entries on the report.

•All entries should be initialed by the person making the notation.

Medical Progress ReportStep3•Summarize briefly the patient's primary

complaint and description of symptoms, current medical conditions and past medical history, including relevant facts from the family medical history.

•Note any aspects of the patient's lifestyle, which present significant risk factors (e.g. smoking, alcohol/drug abuse).

Medical Progress Report

Step4

•Describe any abnormalities noticed when performing a physical examination.

•Log the patient's vital signs and the details of even subtle changes observed in the patient.

Medical Progress Report

Step5•Make notes related to the patient's diet,

as diet can sometimes affect a person's progress. For example, certain foods are known to interfere with medication, either increasing or decreasing a drug's effectiveness.

•Food can also cause allergic reactions and should be ruled out as the cause when a drug allergy is suspected.

Medical Progress ReportStep6•Keep a record of labs, diagnostic tests and

any imaging studies. Be sure to indicate the date on which the tests were ordered. Record the results. Write a brief summary about any procedures performed, as well as the findings.

•The report should describe the patient's response to treatment, whether successful or ineffective. Make a note of impressions offered by other healthcare practitioners as the result of medical consults.

Medical Progress ReportStep7•List all medications the patient is currently

taking. Include the name of the medication, strength, dosage and prescribed route of administration (e.g. oral, injected, topical, inhaled).

•Identify any medication that is being discontinued. Include the name of the drug and the type of reaction. Medication history should also include any nonprescription drugs or herbals the patient is taking.