Medical Report Writing Essentials
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Questions and Answers

What is the first information to be fulfilled in a medical record or clinical note?

  • Patient's ID number (correct)
  • Patient's date and time of visit
  • Doctor's name and position
  • Patient's chief complaint
  • What should the chief complaint in a medical report primarily include?

  • Doctor's own summary phrase
  • Abnormal exam/lab findings
  • Patient's own words about the symptoms (correct)
  • Diagnosis established before the patient arrived
  • What should be included in medical records according to the text?

  • Every consultation by email or letter only
  • Only physical consultations
  • Every consultation by telephone, video, email, or letter (correct)
  • Every consultation by telephone or video only
  • What distinguishes an original medical report from a medico-legal report according to the text?

    <p>Inclusion of degree of impairment assessment</p> Signup and view all the answers

    What is a requirement for writing a medical report according to the text?

    <p>Possession of a detailed patient medical record</p> Signup and view all the answers

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