Medical Report Writing Lecture 1 & 2 Summer 2024 PDF

Medical Report writing Medical Report Notes Prepared by Professor/ Ahmed El- Tawdy Summarized by Professor/ Rania Hamed  Mission and Vision of Faculty :‫رسالة الكلية‬ ‫...

Medical Report writing Medical Report Notes Prepared by Professor/ Ahmed El- Tawdy Summarized by Professor/ Rania Hamed  Mission and Vision of Faculty :‫رسالة الكلية‬ ‫تلتزم كلية الطب جاهعة الدلتا إلى تقديـن برًاهج تعليوىى هويىز يى إل إلىى ت ىريج قاىاي ىاإريي يلىى تقديىـن تطى ير‬ ‫ال دهة الصحية للوجتوع للورضى ى يك ً ا اإريي يلى التعلين الوستور الاحث العلوى لهن بىا ىىى الوسى لية‬.‫الوجتوعية‬ The Faculty of medicine – Delta university is committed to provide a distinguished educational program that leads to the graduation of doctors who can provide health services to the community and patients, continuously learn, do scientific research, and have social responsibility.  Mission and Vision of Faculty :‫رؤية الكلية‬ ‫تسىىعى كليىىة الطىىب جاهعىىة الىىدلتا لتك ى ى ه سسىىة تعليويىىة هتويىىز ىىىى التعلىىين الطاىىى الحىىديث الاحىىث العلوىىى يلىىى‬.‫الوست ل الق هى العالوى‬ The Faculty of medicine – Delta university seeks to be a distinguished educational institution in the modern medical education and scientific research at the national and international levels.  Learning outcomes  Define the medical report  Recognize the significance of medical reports  Outline the requirements of medical admission report  Summarize the requirements of discharge notes  Learning Outcomes 1. Meaning and significance of medical reports 2. Admission report 3. Discharge summary 4. Difference between medical reports & medico-legal reports 5. Comparison between oral presentation & written clinical notes 6. Summary and wrap up Definition of medical report Official detailed document written by doctors including the patient’s:  History  Complaint  Findings of clinical examination  Results of investigations  Treatment given to the patient  Conclusion (diagnosis)  Prognosis and outcome of the patient Importance of medical report:  Important tool for communication  Help in identifying the medical condition  Guide the personalized treatment plan  Monitoring the patient  Used by companies and insurance providers to assess health insurance eligibility and medical leave. Admission Report Why we write admission report?  Tracking patient’s information for your own sake  Deliver information for other healthcare providers  Documentation for future medico legal purpose (reduction of malpractice claims)  Titles under which you write admission report I-General information: Patient information 1. Patient name (first name, family name) 2. ID number (either the insurance number, hospital number, or social security number). Title of the clinic or department Date / time (Sunday, 1st of August 2021 at 10,00am in general surgery out-patient clinic) Your full name and position (House officer or senior registrar or intern or consultant) II- Personal history and special habits:  Name  Age  Sex  Residence  Occupation  Marital status  Special habits III- Goals of care: (seeking advise for new symptoms or follow up visit, or consultation for treatment or follow up investigation asked for…..etc) OR Complaint The chief complaint is the patient`s primary reason for seeking medical attention. It is in the patient`s own words  Some mistakes in chief complaint Original chief complaint Error Correct chief complaint Mr. Essam is 65 y/o man It includes the presumed Mr. Essam is a 65 y/o presenting with a heart diagnosis man presenting with attack chest pain for 3 hours Ms. Amal is a 14 y/o girl It includes lab result that Ms. Amal is a 14 y/o girl with no significant was presumably not with no significant medical history known at the time of the medical history presenting with diarrhea patient arrival presenting with diarrhea for 1 week and for 1 week hypokalemia Original chief complaint Error Correct chief complaint MR. Mohamed is a 58 It includes irrelevant Mr. Mohamed is a 58 y/o y/o man with gout Lt. medical history. man with peptic ulcer Knee arthritis, chronic It includes disease, presenting with low back pain, and peptic interpretation of the sever epigastric pain for ulcer disease, presenting exam rather than the 45 minutes. with acute abdomen patient`s presenting symptom. IV- HPI (history of present illness) write it as a detailed story The HPI is like telling a story. Chronology ‫ التسلسل الزمنى‬is extremely important. It should include Key events, and only relevant information. Symptoms should be described in addition to be listed (e.g. location, onset, duration, severity, quality context ‫فى سياق الكالم‬, etc……………. ) V- PMH (Past Medical History) Unlike HPI, the PMH should always be written as a list, rather than a prose. Omit any item of PMH that is completely resolved & of no relevance to the chief complaint (e.g. broken arm in childhood, typical pneumonia 10 years ago …etc). State chronic disease markers when relevant e.g.  Baseline weight in CHF (chronic heart failure). Last HbA1C in diabetes. Base line Creatinine in chronic kidney disease VI- Past surgical history VII- Prescribed medication history: VIII-Allergy: From what? Type of reaction (rash, swollen tongue, stridor…etc. IX- Physical examination (O/E) observer examination Vital signs: (heart rate, blood pressure, temperature, respiratory rate) Be sure these values are not due to drugs or any intervention e.g HR is normal not due to inotrops or pace maker insertion and oxygen saturation is 96% not due to nasal mask or ventilation Finding of general examination X- Investigations : XI- Assessment: XII- Plan: Admit the patient. Treatment and follow-up. Dietitian Discharge Report What must be done before writing the discharge Report? 1- Be sure that is the patient definitely leaving the hospital and when the patient is going to leave?  If you are in the morning and the patient will leave at night so, your priority is to write the discharge report in the morning before you get busy or leave the hospital WHY Because the report takes time from you and give the clinical pharmacy and nursing team to finalize their work. 2- Collect all the patient clinical notes before writing the report including why the patient admitted to the hospital (from the emergency department, transfer from other department) and duration of hospital stay 3- Make sure that the patient knows that he/she is leaving the hospital What to include in the discharge report? 1. Summary statement related to the principal problem (patient age, gender, symptoms that presented with, presumed diagnosis and the reason of admission). 2. Active problems should be included in the discharge summary and should be listed in order of importance and Written as follows:  Separate bullet points (where each active problem has its own paragraph).  Story (story or narrative style).  Brief description of each active problem must have: a. Evaluation. b. Treatment. c. Outcome. d. Complications (unexpected events, adverse reaction or medical error) e. Follow-up. 3- Patient instructions: to help patient and physician understand and remember what they need to do after leaving the hospital  New medications and medications stopped or changed during patient stay and the reasons for medication changed.  Activity orders  Dietary instructions  Primary care physician follow-up and future appointments What to do once the letter has been completed? 1. Remember that you do not miss any important point in your report (because this is a document). 2. The report must be signed and sent to the General practitioner. 3. Avoid any specialized language (medical language). 4. The report should contain all pertinent ‫ذات صلة‬ findings (important physical examination and lab results of the patient). Comparison between oral presentation & written clinical notes Comparison between oral presentation & written clinical notes Similarities Overall format is identical in (CC, HPI, PMA, Medications etc…..) Differences Oral presentation Written note  Purpose:  Purpose: Rapid communication. Detailed reference. Real time decision making. Legal document.  Avoid excessive detail.  Comprehensive  Ethical challenges: - Maintain confidentiality and security measures - Honesty and accurate data insertion Summary and wrap up