How to write a medical report

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There are many different types of medical reports, written for different reasons. If you work in the healthcare industry, you must often write medical reports. You also may need to know how to write a medical report if you care for a sick person in the home.

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  1. 1

    Know that a common type of medical report is written using the SOAP method. This stands for Subjective Objective Assessment Plan. The subjective part of the report tells what the patient says about his symptoms in his own words. The objective part of the report details what you see and hear when you observe the patient.

  2. 2

    Assess the patient after observing her problems and symptoms. When you write a medical report, this is where the analysis of the condition is noted. Tell what conclusions can be drawn to assist the diagnosis. Document all the facts accurately and concisely. The information in the report must be timely and confidential so that it can serve as a legal document if necessary.

  3. 3

    Write the Plan part of the medical report. The plan includes the overall treatment, any medications used and any other therapies involved in caring for the patient.

  4. 4

    Note any problems when you write a medical report. Write the date and time beside each entry. Enter medications or treatments as given. When you are writing a medical report using the focus charting method, use dark ink and write legibly. Never skip lines when writing a medical report.

  5. 5

    Draw a single line through any error you make when you're writing a medical report. Never erase or white out an entry. This is particularly important for legal reasons. Put your initials beside the error line.

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