How to Write Medical Report: Worst Mistakes

how to write medical report

Medical Report Writing Rules

Medical report writing is full of rules. Most scientific writing is. While sometimes it seems like there are entirely too many rule most of them have a valid reason. Violating some of the rules might detract from your nursing capstone paper but not too much. There are some that will completely sink your report if you don’t obey them.

Here are some of the more important rules to keep in mind when writing a medical report:

  • Written consent from the patient: There is no getting past this one. Medical ethics require that a patient give their written consent before you include them in any medical report. You are also obligated to protect their privacy if permission is granted, and should remove anything from the report that could identify them
  • Citing resources: This is another rule that is taken very seriously. Citing a source incorrectly is bad. Failing to cite a source is plagiarism. Plagiarism will sink a paper and even a career. In the academic world, it’s about the worst crime you can commit.
  • Follow the proper structure: Using the wrong structure on your paper will get it marked down considerably, but on its own, you might squeak by if you rewrite it correctly depending on the instructor’s mood.
  • Follow the tenets of good English writing: The rules of English grammar and punctuation apply. One slip up won’t destroy a paper but allowing two or three spelling mistakes and/or grammatical errors get by you is going to draw some attention
  • Incorrect data/information: If it is determined it was deliberate it is as bad as plagiarism. If by accident you may be viewed as lazy, careless, or not to bright. Double check everything
  • APA style guide: Medical report writing follows the APA style guide. When in doubt regarding the way to cite a particular reference, create a title page or anything else to do with style and format, the answer can usually be found there.

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How 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.\

medical report writing

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.

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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 other significant 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.

Suggestions and Tips for How to Write Medical Report Papers

Writing a medical report doesn’t have to be something to dread. There is a strict structure to follow, but that can be considered an asset as it lets you know what information should go where. That can be half the battle when writing a paper.

The following suggestions and tips will also help when it comes to how to write medical report papers:

  • Write clearly and concisely: Think about how to write medical report papers using as few words as possible while making sure you are clearly understood. In most cases, brief is better.
  • Write medical reports in the active voice: Reports in the active voice read easier and also are more concise
  • Don’t try and edit and revise while writing the first draft. Get everything you want to say written down then go back to clean it up
  • Follow basic rules of English: Use proper grammar.

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Avoid Mistakes That Detract from Your Paper

Avoiding mistakes is a big part of how to write medical report papers correctly. The potential for mistakes occurs at every stage of the writing process, and some mistakes can eliminate any chance the report has of being found acceptable.

The following are some of the mistakes that you should watch out for:

  • Writing style: Writing in a style that is too informal can really hurt a paper. Although a medical report is generally considered a type of anecdotal evidence, you still must write using the appropriate style and tone
  • Too little or too much detail: When writing a medical case report there is a fine line between too much and too little detail. The tendency is to include more than is necessary. Only include information that is relevant but make sure there is enough to make the “story” clear to the reader
  • Poor organization: The structure should not be altered. It handles much of the organizing for you. Not following proper structure can sink your nursing capstone
  • Being judgmental: Describe events accurately and honestly. Do not moralize on behavior of the patient. Stick to the case itself. Being judgmental will hurt your credibility
  • Improper citations/no citations/plagiarism: Citing references incorrectly or failing to cite a reference can result in charges of plagiarism. That is about the worst thing you can do in academic writing

If you aren’t sure what mistakes must be avoided, have a problem with any aspect of the medical report writing process or don’t know how to write a nursing care plan at all, our medical writing service is standing by to help.

Top Quality Medical Report Writing and Editing

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how to write a medical report

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