Medical Report Format
One essential thing that any hospitals should provide is a medical report of each patient. Medical report is a document about the medical examination that a patient has encountered. The doctor uses it as information to know and assess the diseases the patient has and to handle them. In addition, medical report is also important to determine what to take if any further medical examinations or assessments are required. However, without providing a good medical report, it can appear difficulties to understand the medical history of the patient. Therefore, it requires a good medical report format.
A clinical report format should, at least, contain:
- Name of patients
It provides the full name of patients.
- Subjective
It provides the personal details of patients. What age, what complains they have, what symptoms they get, and other details they have been complaining about.
- Objective
It usually provides details in general such as how well their bodies are, what happens to their noses, their lungs, their neck, and so on.
- Assessment
This provides the assessments that the patients might have.
- Plan
It provides the plans, by the doctors, that the patients should examine based on the assessments they encounter.
- Doctor’s name
This part provides the doctor’s name that is responsible for the patient.
The medical report format has some purposes:
- To proceed legally to the health care of patients
These legal documents are in different consent for medical examinations and treatments.
Examples: Mental health recommendation, protection reports, assessment of mental capacity
- To help forward public good
Doctors exercise the function of public health including the examples below.
Examples: Diseases notification, injuries evidence for criminal results, reactions of adverse drugs, cremation certificates
- To excuse factors for illness
This is one largest category because one satisfactory system thinks that to excuse factors for illness has not yet been able to process sickness benefit.
Examples: Supporting report for academic inquiries, holiday insurance, supporting letters for absence the court, supporting letters for exemption the jury services
- Grounds for illness entitlement
It is a medical assessment format that is gained to certify that the patient or applicant is fit to be in responsibility.
Examples: Housing letters, war pensions, letters of social security, cancellation of holiday insurance, medical events account to proceed as civil, disability form, mobility allowance form, and medical paying exemptions
- To be able to fulfill requirements for applying job
This is usually used for applying job that requires a medical report to accomplish one of the requirements. It is taken to get licensed for work. In addition, it is done to make sure that the patient or the applicant is able to work accordingly.
Example: PCV licenses, LGV licenses, summer camp, health professions, actuarial calculation, taxi driver
- Life assurance
It is usually used to fulfill the requirements for applying assurance. It aims to help assessing the diseases or death risk accordingly.
Example: Sickness insurance
The medical report format is one essential thing that any hospitals should provide for their patients. It is advantageous to help doctors assess the treatments the patients take best. In addition, the medical report format is also used for any other purposes such as: for applying job, life assurance, to process the health care, etc.
Medical Report Format
