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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 Reports
- Medical History
- Physical
Examination
- Physician Orders
- Progress Notes
- Laboratory
Reports
- Radiology Reports
- Other Diagnostic
Procedures
- Medication Sheet
- Consent Forms
- Consultation
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.
CONFIDENTIALITY
CONSENT 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 Report
Step1
• 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 Report
Step2
• 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 Report
Step3
• 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 Report
Step6
• 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 Report
Step7
• 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.