Advancing technology has led to the invention of new medicines along with the tools that make it easier to detect and treat diseases. Every hospital follows a set of rules pertaining to the treatment of their patients which help both parties. These rules are in reference to the admittance of patients and how they are given health care at the particular facility.
A medical report refers to the information collected from the patient while admitted and it also provides insights about the doctor who will tend to that patient. Most medical reports include a diagnosis, prognosis, treatment plan, and follow-up which provides a complete picture of any unknown person.
A medical report can be defined as the findings of a doctor related to a patient. A medical report includes everything that has been tested and found out about a patient’s medical health and describes each and every aspect in detail.
Data collected by the patient
Medical reports are filled by hospital staff at the reception after asking relevant questions from the patient or their relatives. Initial data collected from the patient helps a doctor to prescribe a suitable treatment plan. Medical report layout refers to the pattern of how reports are made, and the history of the patient is collected. Some of the information mentioned in the medical report is given below,
- Name and age of the patient
- Address and phone number
- Relatives present at the time of admittance
- Health conditions
- Previously prescribed medicines
- Allergies or inflammatory responses of any kind
- Tests, scans, and x-ray reports
- Date of hospital admittance and discharge
- Name of doctor
- Treatment plan
- Prognosis
- Follow-up dates
All the information provided on the medical report clear image of the patient’s condition and treatment plan which can help another doctor or person.
Sample and significance
Although the medical report layouts of every hospital are similar, many hospitals add detailed information about the patient and their treatment because these reports can be used in legal matters i.e. paternity issues, harassment, etc. Therefore, a detailed layout of the medical report at any hospital is given below,
Hospital Medical Report
Registration number: ……………
Information about Patient
Name: ____________
Age: ____________
City: ____________ Country: ____________
Address: ____________
Gender: ____________
Phone: ____________
Information about Doctor
Name of doctor: ____________
Department: ____________
Initial symptoms: ____________
Diagnosis: ____________
Treatment plan: ____________
Prescribed medicines: ____________
Follow-up date: __/__/__
Date of hospital admission: __/__/__
Date of discharge: __/__/__
Doctor at discharge: …………………..
Significance
The medical report layout is helping tremendously in every way by providing information about the patient and his condition. Its significance can be evaluated from the following points,
- The medical report layout outlines all important points about a patient’s history.
- All the allergies to any food item or medicines are clearly mentioned helping doctors to prescribe appropriate medicine.
- In case of changing doctors, new doctors get informed about the patient’s condition in less time.
- Information from the hospital and doctor allows anyone to follow back and check the veracity of the report.
- It can be used for legal matters and can also be presented in a court of law.
- A medical report is taken seriously and is accepted worldwide.
- Scans and test results attached to the report are widely accepted everywhere.
- Every hospital keeps a copy of their patient’s medical report which can easily be referred to in case anyone loses their copy.
- Helps patients to know about their condition and ask doctors accordingly.
Few other details of the report
Some other details of a report are as follows
Medical report for documentation
This medical report is issued by the doctor or by the medical officer that has been looking after the patient. This report can include the findings and the test results along with any recommendations or treatments that the doctor or the medical officer has advised the patient to undergo. This is for documentation purposes for both the patient and the hospital.
When drafting a medical report it should be taken into account that this report is very important to the patient and to the hospital, and it should be written in a detailed manner otherwise it serves no purpose. It should also be organized and neat by using various headings and subheadings and highlighting anything which is of importance.
Drafting the report layout
Since the medical report is a professional one, the use of colored fonts or fonts that aren’t professional shouldn’t be used. It is best if Times New Roman or Calibri is used since it reflects a professional demeanor. The report can include the logo of the hospital as well. Apart from the writing aspect, the presentation of the report is equally important. Make sure it is presented in a file and is made using quality materials.
Following is given a sample of the medical report layout. One can use this layout to create a wonderful medical report for personal or professional use.
Preview
