Download Medical reports for different circumstances

Medical Report Writing
Sharing Session on 22.1.05
Medical reports for
different circumstances
General Direction
• Provide unbiased , factual
information , relevant to the
purpose of the request
• Be concise and precise
• Comprehensible by non-medical
readers
• Except those written as medical
references/ referrals
Format
• Refer to the request-from whom,
date, reference numbers
• Disclaimer- “The above
information is extracted… ..”,
“The above information is to the
best of my knowledge… .”
• Remember to read the request
letter.
Legal/ Insurance claims for
Injuries on Duty, Traffic
Accidents
• Admission date/ time, mode of injury
• Exact diagnosis, treatment,
operations
• For vague or non-specific symptomsspecific physical/ investigatory
findings
• Admission and discharge dates
• Sick leave start and end dates
• Expected disability
Patients with
complications or complaint
cases
• Respond promptly
• Ensure that all major events are covered,
esp. operations and complications
• Failing to do so might be construed as an
intent to mislead or hide unfavourable
facts, or even alleged as “cleaning up” the
records or covering up mistakes
• Team head or i/c must check and
countersign
• Hospital management must be notified in
case of potential claim
Background surveillance
for new insurance policies
Pertain to writer’s specialty
Period under care
Diagnoses and treatment
Specific physical, radiological and
other objective findings
• Include known chronic illnesses or
habits, even though not diagnosed
by us- e.g. diabetes, hypertension,
drug abuse
•
•
•
•
Background information
for the Coroner
• Be concise and precise on
background information
• Provide relevant details for facts
that might be related to the cause of
death- chronic illnesses, chronic
medications, mental illness, drug/
alcohol abuse, recent severe illness/
operations
• Pertain to writer’s own specialty
field
Coroner ‘s request for medical report
in year 2004
• The above named patient was first seen at our specialist
outpatient clinic on 1991. He complaint of right shoulder
pain at that time. On physical examination , there was
tenderness around right shoulder with satisfactory range
of motion. X-ray showed no bony lesion. He was treated
conservatively with analgesics and physiotherapy with
satisfactory progress. He also complaint of left shoulder
pain later on which was treated conservatively again.
• The above named patient was first seen at our specialist
outpatient clinic on 1991. He complaint of right shoulder
pain at that time. On physical examination , there was
tenderness around right shoulder with satisfactory range
of motion. X-ray showed no bony lesion. He was treated
conservatively with analgesics and physiotherapy with
satisfactory progress. He also complaint of left shoulder
pain later on which was treated conservatively again.
• The above named patient was
followed up at our specialist clinic
for bilateral shoulder pain since 1991.
The symptoms responded well to
conservative management.
•
He had history of gouty arthritis and with intermittent knee and
ankle pain which responded to conservative management. He
was under regular follow up till 2004.
•
He was admitted to surgical ward on 20th March 2004. Our
department was consulted for right shoulder pain. X-ray showed
fracture of right humerus surgical neck and greater tuberosity.
•
He was treated conservatively with sling and analgesics. On his
latest follow up on 19th April 2004. X-ray was taken and
revealed satisfactory healing progress. There is no further
information since then.
•
He had history of gouty arthritis and with intermittent knee and
ankle pain which responded to conservative management. He
was under regular follow up till 2004.
•
He was admitted to surgical ward on 20th March 2004. Our
department was consulted for right shoulder pain. X-ray showed
fracture of right humerus surgical neck and greater tuberosity.
•
He was treated conservatively with sling and analgesics. On his
latest follow up on 19th April 2004. X-ray was taken and
revealed satisfactory healing progress. There is no further
information since then.
• He also suffered from gouty arthritis which responded
well to conservative management.
• In March 2004, we were consulted while he was
admitted under department of surgery. Fracture of the
proximal part of the right humerus was treated
conservatively. He was last seen at our clinic on 19th
April 2004 when the fracture was progressing well.
Patients under joint care,
consultation cases
• Pertain to writer’s own specialty
• No need to provide details of
circumstances- e.g. date of
admission, detailed history, etc.
• Stick to problem consulted, and
the treatment of the consulted
problem.
Medical referral/
reference
• Provide relevant details for
continued care of patient
• May use medical language or jargons
• Include landmark laboratory results
and other investigatory findings
relevant to the situation
• Include operations and medications,
esp. chronic meds.
• Include alert and allergy information
Medical board reports
• Use standard reply forms (file)
• Do not respond to questions which
involve HR decisions- e.g. whether
the patient should retire
• Only recommend restrictions/
limitations
• Some cases involve the decision to
hire or fire – don’t get involved in the
fights.