Medical report [Neurosurgery Wiki]

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====== Medical report ======

A **medical [[report]]** is an official [[document]] that provides detailed information about a patient's [[health status]], [[medical history]], [[diagnosis]], [[treatment]], and [[prognosis]]. It is typically written by a healthcare [[professional]], such as a doctor or specialist, and serves various purposes, including:

1. **[[Clinical Documentation]]** – Recording patient progress, diagnoses, and treatments.
2. **Legal Evidence** – Serving as a [[legal]] record in cases of medical disputes or insurance claims.
3. **[[Communication]]** – Facilitating information exchange among healthcare providers for coordinated care.
4. **Research & Education** – Contributing to medical studies and training.

A medical report may include:
- Patient’s details (name, age, gender, etc.)
- [[Medical history]] (previous conditions, allergies, medications)
- [[Examination]] findings (physical, neurological, or laboratory results)
- [[Diagnosis]] (including differential diagnoses)
- [[Treatment]] plan (medications, surgery, therapy)
- Follow-up recommendations