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How Do I Do A Medical Report?



  1. Know that a common type of medical report is written using SOAP method.
  2. Assess the patient after observing her problems and symptoms.
  3. Write the Plan part of the Medical report.
  4. Note any problems when you write the medical report.

How do you write a patient report?

III. Patient case presentation

  1. Describe the case in a narrative form.
  2. Provide patient demographics (age, sex, height, weight, race, occupation).
  3. Avoid patient identifiers (date of birth, initials).
  4. Describe the patient’s complaint.
  5. List the patient’s present illness.
  6. List the patient’s medical history.

What is included in a medical report?

A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.

How can I get NYSC medical report?

It is quite easy to get medical fitness report. All you need to do is walk into any Government or Military hospital and tell them you need a Nysc medical fitness report. This can either be State or Federal owned hospitals.

What is a full medical report?

A medical report is a comprehensive report that covers a person’s clinical history. Ideally, your medical report should be completed by a doctor or medical professional who is familiar with your condition and who has treated you for a significant period of time.

How do you start a report?

Structure your report Title or title page. Executive summary/abstract that briefly describes the content of your report. Table of contents (if the report is more than a few pages) An introduction describing your purpose in writing the report.

What is patient report?

A patient report is a medical report that is comprehensive and encompassing a patient’s medical history and personal details. It’s often written when they go to a health service provider for a medical consultation. Government or health insurance providers may also request it if they need it for administration reasons.


How long is a clinical report?

The word count for case report may vary from one journal to another, but generally should not exceed 1500 words, therefore, your final version of the report should be clear, concise, and focused, including only relevant information with enough details.

What are six types of patient files?

01 Oct 6 different types of medical documents

  • PIL. A PIL is a patient information leaflet you can find in any medicine bought at a pharmacy.
  • Medical history record.
  • Discharge Summary.
  • Medical test.
  • Mental Status Examination.
  • Operative Report.

Can my employer ask for a medical report?

An employer cannot ask a medical professional for an employee’s medical records, or information about an employee’s health, without permission from the employee. Employers cannot request that an employee discloses information about any health conditions that arise during employment.

Is medical report compulsory for NYSC?

Medical certificate of fitness should contain certain prescribed tests by NYSC, and those tests are to be taken from General hospital or Military clinic. Medical certificate of fitness is compulsory; any PCM who fails to present it is not going to be allowed to participate in the NYSC programme.

What is the difference between medical report and medical fitness?

Medical Report is a report showing your inability to stay in a particular state of deployment due to your health status. NB: Medical Fitness is a compulsory prerequisite for registration in camp, while Medical Report is used for relocation or for PCM that don’t want to camp.

What is a medical fitness test?

A medical fitness certificate is a document completed by a qualified occupational health practitioner or an occupational medical practitioner. Fit to work examinations are done to determine the medical fitness of an employee for baseline, pre-employment, periodic or exit medicals.

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