Medical Report Outline

Patient Information:

• Full Name: [PATIENT FULL NAME]

• Date of Birth: [PATIENT DOB]

• Gender: [PATIENT GENDER]

• Patient ID/Medical Record Number: [PATIENT ID]

• Address: [PATIENT ADDRESS]

• Phone Number: [PATIENT PHONE NUMBER]

• Emergency Contact: [EMERGENCY CONTACT NAME AND PHONE]

Referring Physician Information:

• Physician Name: [REFERRING PHYSICIAN NAME]

• Specialty: [PHYSICIAN SPECIALTY]

• Contact Information: [PHYSICIAN CONTACT]

Report Date: [DATE OF REPORT]

• Report Prepared by: [YOUR NAME], [YOUR COMPANY NAME]

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1. Reason for Visit

• Chief Complaint: [PATIENT CHIEF COMPLAINT]

• History of Present Illness: [DETAILED HISTORY OF THE CONDITION]

2. Medical History

• Past Medical History: [ANY PREVIOUS CONDITIONS/DISEASES]

• Past Surgical History: [PREVIOUS SURGERIES AND DATES]

• Medications:

  Medication Name	Dosage	Frequency	Start Date
  [MEDICATION NAME]	[DOSAGE]	[FREQUENCY]	[START DATE]

• Allergies: [ANY ALLERGIES AND REACTIONS]

3. Physical Examination

• General Appearance: [GENERAL OBSERVATIONS ABOUT THE PATIENT]

• Vital Signs:

  Vital Sign	Value
  Blood Pressure	[VALUE]
  Pulse	[VALUE]
  Temperature	[VALUE]
  Respiration Rate	[VALUE]

• Head and Neck Examination: [DETAILS OF EXAMINATION]

• Cardiovascular Examination: [DETAILS OF EXAMINATION]

• Respiratory Examination: [DETAILS OF EXAMINATION]

• Gastrointestinal Examination: [DETAILS OF EXAMINATION]

• Neurological Examination: [DETAILS OF EXAMINATION]

4. Diagnostic Testing

• Laboratory Results:

  Test Name	Result	Normal Range	Notes
  [TEST NAME]	[RESULT]	[NORMAL RANGE]	[ANY IMPORTANT NOTES]

• Imaging Results (if applicable):

  Test Name	Result	Interpretation
  [IMAGING TEST]	[RESULT]	[INTERPRETATION]

5. Diagnosis

• Primary Diagnosis: [PRIMARY DIAGNOSIS]

• Secondary Diagnoses (if any): [ANY OTHER DIAGNOSES]

6. Treatment Plan

• Medications: [PRESCRIBED MEDICATIONS]

• Therapies and Interventions: [RECOMMENDED THERAPIES]

• Surgical Procedures (if any): [ANY SURGERIES PLANNED OR DONE]

• Follow-up Care and Appointments: [ANY NECESSARY FOLLOW-UP CARE]

7. Prognosis

• Short-term Prognosis: [PROGNOSIS IN THE SHORT TERM]

• Long-term Prognosis: [PROGNOSIS IN THE LONG TERM]

8. Additional Notes

[ADDITIONAL INFORMATION OR NOTES]

9. Physician

• Name: [YOUR NAME]

• Title: [YOUR TITLE]

• Signature: ____________________________

• Date: [DATE]

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