A medical report is a comprehensive list of medical related-records that is kept by a medical facility or by an attending physician. It is a vital document that can be used for various reasons, especially as a reference for a particular undertaking.
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Medical Report Definition & Meaning
A medical report is detailed documentation of a patient’s medical history such as consultations, medical examination and findings, test results, medications that are taken, and progress report.
Medical reports are prepared and filed physician or a medical professional who is familiar with a patient’s medical history.
What Is a Medical Report?
Medical documents consist of various documents such as medical tests, laboratory tests, discharge summaries, lists of chronic health conditions, and many more. All these data are then summarized into what is called a medical report. Such a document is essential for easy reference and it can be used as a supplementary or main requirement for an insurance claim or for an investigation.
10 Types of Medical Reports
Medical Legal Report
A medical-legal report or medico-legal report is an important document used as a reference or as evidence for investigations. It is imperative that a lawyer is consulted to ensure that the proper procedure is followed when providing this document. A medico-report is written by a doctor or medical professional and is also needed to assess any legal claims.
Medical Incident Report
Incidents are most likely to happen anytime and anywhere including hospitals and clinics. The likelihood of these happening in the hands of an experienced healthcare provider is a common occurrence. To get a detailed timeline summary of what went wrong or what happened, a medical incident report is written by the parties involved.
Medical Status Report
Updating a patient’s current medical status is important in order to gauge their current condition. This kind of data is summarized in a medical status report. This document is particularly important for patients who require long-term care and needs constant monitoring.
Medical Annual Report
A medical annual report as its name suggests is a yearly report that outlines a list of medical-related concerns such as medical issues, complaints, examinations, patient-care reports and etc. The purpose of this report is to give the management a rundown of the different activities and events that occurred in the facility. This report is presented during a board meeting that includes top executives and board members.
Medical Narrative Report
A medical narrative report is another vital document needed when an investigation is launched by authorities. It is a narrative and detailed documentation of a patient’s illness or injury and the flow of events that includes medical examination findings and professional output. For those filing a lawsuit, a well-written and factual medical narrative report help lawyers evaluate the case.
Online Medical Report
Nowadays most reports come in digital or printed format which rings true for medical reports. An online medical report is a convenient way to access one’s record with the use of the internet or a database that the patient or medical professional can use to log in. Other than that this document can be printed or distributed via email.
Standard Medical Report
A standard medical report is a record of a patient’s medical history and activities. It is a general medical report where one is expected to find all important details that may be relevant to any future treatments and investigations. This report is a vital communication tool that benefits not only the patient but other relevant entities as well.
Hospital Evaluation Report
A hospital evaluation report is a detailed record of the assessment made by evaluators regarding a hospital’s medical practices and procedures. Evaluations are conducted to ensure that medical institutions such as hospitals follow the requirements needed to run a hospital. And to make sure that staff and patients are safe and well-cared for.
Patient Progress Report
Patients who still receive medical treatment require a patient progress report so that any attending physician or medical staff will know what they should do next. It is an important communication tool that benefits staff who are involved with patient care and treatment. Included in this document are the assessment, diagnosis, treatments, and medication.
Medical Summary Report
A medical summary report is an outline or a review of the patient’s medical record. It summarizes the condition of the patient, the dates he or she was treated, the treatment location, and other relevant data. It is the patient’s right to be provided with this document for transparency and in case there is a need for further medication.
Medical Report Uses, Purpose, and Importance
A patient’s medical report may be comprised of several reports compiled into one file or is a single comprehensive summary of their medical history. However this is presented, medical reports are not just important to their holder but may be a requirement for employment and insurance claims. This report is a communication tool that holds a lot of data that may be crucial to several individuals and organizations.
For Review
Medical reports are used for current or future references. This is why it should be kept, updated, and monitored whenever an individual seeks medical assistance. As a result, medical reports are used by different organizations or individuals for review before they can move forward.
Insurance Purposes
Medical reports are one of the main requirements for insurance claims. The reason for such is that insurance companies need to make sure that the patient is eligible for compensation. This is why it is vital that the data provided is true, complete, and fair.
Evidence for Investigations
If a patient has been medically mistreated or has been involved in any malpractice then investigators will need a medical report as proof or evidence. A thorough review is conducted and other qualified experts are also consulted to ensure the validity of the said report. And since medical reports provide medical history this may help solve a case or offer relief and monetary compensation to any claimants.
Form of Communication
Medical reports are often reviewed not just by the patients but by several individuals. This can be checked by investigators, insurance personnel, other physicians, the HR department, and other medical practitioners. It is a vital document that provides data to those who require it.
Treatment Plan
Medical reports are required by doctors and other health care professionals in order to come up with the next treatment plan for their patients. By going through the report they are also able to take note of any discrepancies that may endanger the life of the patient. This is why medical reports should be properly monitored and updated when needed.
What’s In a Medical Report? Parts?
Title of the Report
Medical reports are used for several reasons and sometimes these are specifically prepared for a particular purpose such as an investigation or as a reference for an incident report. That said, it is important to write down the specific title so that readers will know what the medical report is all about.
Patient’s Information
A medical report should first and foremost include the patient’s basic information such as their name, address, date of birth, age, gender, and contact details.
Name of the Person Who Prepared the Document
Since a medical report is always prepared by a doctor or any other qualified health professional it is vital to state their name, position, qualifications, and credentials.
Scope of Purpose of the Report
An outline of what the report is all about should be included in the document.
Medical History, Condition, and Other Relevant Details
The most important section of a medical report is the detailed account of the patient’s medical history, conditions, and other relevant details such as any ongoing treatment, medications, and prognosis.
Professional Medical Opinion and Feedback
Health professionals may be required to include their medical opinion and feedback regarding the purpose for which the document is needed. And to also provide output regarding the patient’s current state.
How to Design a Medical Report
1. Select an appropriate Medical Report Size.
2. Specify the purpose of preparing a medical report.
3. Choose a Medical Report Template.
4. Write down all the sections that are relevant to the document.
5. Attach any charts, diagrams, or images as references to the document.
6. Review, finalize and download.
Medical Report Vs. Medical Certificate
A medical report is a written communication tool that informs its reader of the patient’s medical history, treatments, laboratory results, and other health-related issues.
A medical certificate is a document written by a physician or any medical practitioner that authenticates the results of a medical examination performed on a patient/individual.
What’s the Difference Between a Medical Report, a Memo, and a Clinical Case Report?
Medical reports are documents that contain vital information regarding a patient’s medical case that provides readers with an understanding of the medical history and other medical-related matters.
A memo written by a doctor is a brief document that contains a patient’s diagnosis without giving any further information regarding the medical condition.
A clinical case report is a document that is written by various types of medical practitioners that provides valuable insight and observation regarding an unusual case or one that has never been described before.
Medical Report Sizes
Medical reports are widely used by medical practitioners and are essential documents that provide assistance in legal claims and all sorts of investigations, and as a means to provide additional information for future treatment plans. That said, medical report sizes follow the standard paper sizes since they follow a required format that is needed to complete this type of document.
- Letter Size: 8.5 × 11 inches
- Legal Size: 8.5 × 14 inches
- A4 Size: 8.3 × 11.7 inches
Medical Report Ideas and Examples
Medical reports contain all sorts of data related to the health and present condition of a patient. Different kinds of medical report ideas and examples are used to address certain issues as these are attached either as supplemental or as binding documents.
- Hospital Medical Report Ideas and Examples
- Healthcare Marketing Report Ideas and Examples
- Medical Report Illustration Ideas and Examples
- Patient’s Report Ideas and Examples
- Clinical Evaluation Report Ideas and Examples
- Patient’s Chart Ideas and Examples
Medical Report FAQs
What information is included in a medical report?
A medical report should contain a patient’s medical history, current health status, treatments they have undergone, diagnosis, medications and etc.
How long is a medical report released?
There is no given number of days, however, it is recommended that a medical report should be released between four to six weeks.
Can a patient disagree with the information provided in a medical report?
Patients can disagree with the information written in a medical report if it compromises or endangers their life.
What are the things you should not add to a medical report?
A medical report should only contain relevant and factual information and that other matters such as financial information, speculations, legal information, and other sensitive issues that are not relevant to the report.
What are the reasons medical reports are needed?
Medical reports are needed for several reasons such as continuing medical care, and for review, and are used as binding evidence or proof for claims or all kinds of investigations.
Is patient consent required when preparing a medical report?
Patient consent is required when preparing and releasing information to third parties unless the patient is incapacitated, is in a life-threatening situation, or has voluntarily waived their consent.
Why is medical documentation so important?
Medical documentation of any form is important because records provide sufficient information for various cases.
Who is in charge of preparing a medical report?
A physician or any licensed medical professional can prepare a medical report.
Why do insurance companies need a medical report?
Insurance companies need a medical report so they can review the document and check if the patient can be compensated.
Are medical reports confidential?
Medical reports are supposed to be confidential and should only be released to those authorized, yet when a medical report is needed for a criminal investigation, some bits and parts of it can be released to the general public for viewing.