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