How to write a medical report

Medical examination methods

To write a report about the patient, the patient must be diagnosed and identified. There are methods of medical examination:

Clinical examination : When the doctor examined the concrete and observation by the senses and through laboratory images and complex, such as radiation, and the use of medical tools such as the medical earphone and others and all the patient’s bed, and the writing of the medical report depends on the diagnosis of the disease and knowledge by the doctor who is writing the report.

Steps for clinical examination

• Care and observation in the patient: the shape and the general body of the patient, a comprehensive examination of the consideration, such as: the presence of certain signs on the skin seen by the doctor or the presence of pallor in the face and others as an assessment of the patient’s overall status of the ratio is very good to excellent and also length and weight and change, Doctor for diseases that appear on the human and do not need to conduct some tests.
• Sense: It is that the doctor sense the patient by touch, such as the following things: measuring the patient’s pulse and lymph nodes, tumors, inflammation and other things that the doctor by touch.
• Use of the patient’s full examination tools and be heard by the patient such as the medical speaker and the sound and other things that are done by listening to the patient.

Important: The clinical examination of the patient reduces the time and effort of medical reports and other excess things and the diagnosis of the patient is more accurate and follow-up which reveals things that other tests can not detect because they include all the patient’s body and the accuracy and success in diagnosing and improving the condition of the disease.

To write a medical report you should know the following about the disease:

• Chronology: Chronic and other diseases include family and relatives and their extension.
• Age and medical qualification of the patient.
• Sex Male or Female.
• Assessments and preliminary tests of the patient: the number of hospital admissions and medical and clinical tests for blood samples and others.

The patient must be fully evaluated and have full check-ups to access the medical report writing and then based on the information received we write the medical report.

Medical report writing

There is some information that should be included in the medical report:

• name of the hospital .
• Doctor’s Name: He is the one who performed the medical examination.
• Functional degree of the doctor.
• Date and date of signature of the report.
• Detection Hour: The medical report is known in minutes.
• Name of the quadriplegic patient.
• Sex of the patient.
• Age of the patient.
• card number .
• Patient Function: This is indicated if the medical report is intended for sick leave. The name of the job must be placed so that the patient can take the leave.
• Address .
• There is some information about the infection:
• Patient Infection: It describes the disease that appears on the patient.
• Number of casualties.
• Type of injury.
• Whereabouts.