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How to Write a Better Medical Report by Brian Konradt

If you're in the healthcare industry, you'll never run out of documents to do. Known as medical reports, these documents are essential to case studies and insurance claims. As for the actual documentation, they're usually accomplished by doctors and medical transcriptionists.

As someone who isn't fully-trained to be a transcriber, you can still write your own medical report. However, you have to write it in a certain format which fellow health practitioners would understand. You'd also have to be fast and accurate to submit it on time for coding and billing.

Basically, the key to writing a medical report would be to follow the standard SOAP format. SOAP stands for Subjective, Objective, Assessment, and Plan. This format applies a step-by-step approach from check-up to treatment.

Step 1: Follow the format of your medical report.

As a preliminary step, know what type of medical report you're writing. Are you preparing a History and Physical, or are you writing an Operative Report? Does the patient require an Initial Evaluation, or is he being furnished with a Discharge Summary?

Given a few differences in their headings and content, all four reports still follow the SOAP format so let's stay right on track.

Step 2: Write the Subjective part.

This is based on what the patient says when he presents to the emergency room, clinic, or hospital. In his own words, he describes the symptoms he feels and the events which led to the accident or illness. These are all noted down by the doctor as complaints on the patient's part.

Since you'll be bombarded with medical terminology from hereon, a medical dictionary such as Stedman's would be of great help! So would a wealth of other medical resources available in software or online.

Step 3: Proceed to the Objective part.

For an attending doctor or primary care physician, this is based on what you observe in the patient. It is further supported by the patient's past medical history.

A very detailed part of the report, it includes data on vital signs such as temperature, pulse rate, blood pressure, and respiratory rate. It also records weight and height.

Step 4: Write the Assessment.

Based on the problems and symptoms which a patient presents, the doctor can make an initial assessment. From there, he moves on to an analysis of the condition.

But before a diagnosis can be written, certain diseases must first be ruled out. This is accomplished through diagnostic tests which have been specifically ordered.

Step 5: Take note of the Plan.

Otherwise known as the treatment plan, this includes all medications and therapies which were prescribed.

Here's the part where you can't afford to make any mistakes in writing down the names of drugs and their specified dosages.

Step 6: Keep the document private.

Since a medical report is considered as a legal document, it is confidential in nature. Thus, it would be highly unethical to ask someone to review your report, edit its content, or proofread it for you.

Since self-editing seems to be a major part of writing a medical report, you have to be pretty accurate in content. Should there be any errors or erasures in your report, make sure you countersign them.

In fact, if you were to be professionally graded for it, nothing less than 99% accuracy would do. After all, there's almost no room for error where life and health are concerned.