How to write a medical report: Guideline

how to write a medical reportHow to write a medical report in 5 stages

Medical reports usually describe an unusual occurrence or some unique feature in a disease or treatment. Some medical reports also contain a literature review of other reported cases that are similar. The case doesn’t have to be unusual but they usually are because unusual and unique cases provide a better opportunity for publication. There are five stages for writing medical reports:

  • Find an unusual case: Look for patients who have rare or unusual illnesses. Treatment plans with an unexpected positive or negative outcome are also cases you can use.
  • Literature search: Review the current literature relevant to the case your medical report will cover. This information will make up a large part of your medical paper.
  • Collect information related to the case including consent: Get the patient’s demographic information such as age, medical history, medication use and such including patient’s labs, radiographs or any clinical photographs. Medical ethics requires that the patient give their written consent as well.
  • Summarize and write the medical report: Write the medical report. The format is similar to that of any healthcare report.
  • Revise and edit: Ensure information is presented logically and mechanical errors are eliminated

How to write medical report using the required format

The following outlines the structure of the medical report and what each section should contain:

  • Introduction: Describe your case using a single sentence
  • Case report: Write a brief paragraph on each of the following
    • History: Patient information, main concerns and symptoms, medical and family history, relevant past interventions and outcomes
    • Clinical features: Description of the physical examination and othersignificant clinical findings
    • Investigation: Diagnostic methods and challenges
    • Treatment and outcome: Types of intervention, administration of intervention and changes in the interventions
    • Progress: Follow up diagnostics
  • Discussion:
    • Review of literature: Discussion of the relevant medical literature
    • Arguments: The rationale for conclusions
    • Message: What lesson was learned from the report
    • Recommendations if any
  • References

Be sure to get the patients signed consent and to protect the identity of the patient. If you aren’t sure of how to write a medical report our medical writing service can help.

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