Consultation reports are an important deliverable in the medical world, and are emerging in the business world as well. They're designed to serve as a report of a patient's initial medical assessment and are used as points of reference as the patient receives treatment and diagnosis for any type of medical ailment. Assembling and writing a good consultation report follows a few basic principles.
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Write the heading of the consultation report at the top. For example, if it's a psychological assessment, you may want to title it "Psychological Consultation Report".
Write four or five line items in the first section of the report that should include the patient's name, age, the date of consultation, location of consultation, and the name of any referring doctor if applicable.
Title the next section "Circumstances of Evaluation", then write out the reasons that the patient is seeking treatment. If he was referred to a psychiatrist by a psychotherapist, then you would explain the reasons why the therapist referred the patient to your medical practice.
Write the following section on the patient's medical history. Feel free to subdivide this section into patient history and familial medical history, noting pertinent details that may cause the patient to have genetic predispositions to certain medical conditions.
Write a section on the current medical status of the patient and include information on any treatment that she may already be receiving for the condition for which she is seeking treatment.
Conclude the consultation report by writing up the recommendations for the patient. If he should be receiving a certain medication or if he needs to be referred to another doctor, you would include that information in the recommendations section.
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