Every medical diagnosis starts with a medical history and background research. It’s important to have a well thought out medical summary report so you can have the entire important patient details documented. It is for the same reason that these reports have to be very precise with all basic criteria covered to ensure nothing is missed out. These reports have to strike the right balance between brevity and information-richness, which makes it essential that you have reliable templates at your disposal. Or, you may create your own medical summary report template. Read on.
5 Steps to Write Medical Summary Report
Step 1: Physical Description & Observations
This is the basic step to cover the physical appearance and symptoms on a patient which would form the basis of the initial diagnosis. This would include height, weight, clothing, hygiene, grooming, assistive devices if any, speech problems, unusual movements, demeanor, etc. Include all these, and other basic information at the top of your template.
Step 2: Personal History
This would include past and current living situations, family background, marital status, trauma victimization if any, education, legal history etc which would help analyze if there has been any medical history of diseases that run in the family and/or mental health status in the current situation. This information is important for medical practitioners to offer contextualized advice to the patient.
Step 3: Occupational History
This part is purely for estimating the occupational hazards that could have an impact on the patient or the kind of financial situation the patient is in. This data would also be able to provide the kind of environment the patient has been previously exposed to. This forms an essential part of the medical summary report, and hence must be duly captured in it.
Step 4: Substance Use
Another vital part of a medical summary report is the information on substance use. This part is to be covered in details like using drugs or alcohol along with intense details like the timeline of the abuses, if any treatment has been received or not, counseling therapy has been done or not etc.
Step 5: Functional Information
This consists of the information on what kind of interactions the patient has, maintenance of pace in their interactions, social behavior and also a thorough analysis of ongoing behavior. There are some other areas to cover here like the assistance needed by the patient in day to day activities.
7+ Best Medical Summary Report Templates
1. Sample Medical Summary Report Template
This is a great option for hospitals and staff to ensure that the medical treatment a patient is undergoing or is about to undergo at the healthcare center is done while aligning with the existent medical summary. This sample medical report summary has demo content for physical description, personal, occupational, substance use history, which makes it a pretty comprehensive document.
2. Free Ongoing Medical Summary Report
This sample medical report template consists of brief descriptions about the physical medical tests, description of response to current treatment, primary diagnosis, details of the medical treatment in the hospital, medications and the insurance. Health surrogate details are also available as demo content for this template, which you can replace and add your own.
3. Minimalist Medical Summary Report Template
This medical report template consists of details that are reported before any discharge. This report consists of visit encounter, diagnosis, course while in hospital, summary course in hospital, discharge plan for the patient along with follow up plan details. This medical summary report is available for download in the PDF format.
4. Modern Medical Summary Report Template
Available in a PDF format, this report sample acts as a guideline for creating a report according to your requirement. This offers demo content for the particular case of a patient with a brief intro to the medical condition and related information on visual, cognition a well as neuro-ability serving as a guideline to draw an assessment.
5. Elegant Medical Summary Report Template
This medical summary report template in black and white draws a clean-cut outline for noting down patient record. This template includes patient and doctor’s particulars, medical information, clinical history, findings, financial issues, welfare or property related information relevant to the payment, investigation results and diagnosis. The dark headers of the template give it a lot of class and control, both desirable traits of a medical summary report, for a modern medical business.
6. Professional Medical Summary Report Template
Available for download in a PDF format, this summary template provides space for logo and hospital/clinic information relevant to the report. It comes with an example for each point covering patient details, with a content table for each point covered in the 15 pages of summary report. So, this becomes one of the most detailed medical summary report examples you can find on the web.
7. Simple Medical Summary Report Template
This colorful test report template serves as a guideline to fulfill your requirement. It is directed to add clinical information of a patient involving factors that may impact the report along with information on the patient. This is a simple format for drawing relevant conclusion based on the report as it covers the history and diagnosis in the form of a case study. Download this comprehensive template and you won’t need another summary format anytime soon.
8. Sample Medical Summary Report Template
As the name suggests, this medical summary report template is one of a kind. It is a complete guide for writing medical summary report including suggestive headings like psychometric analysis, functional information, patient history on substance abuse, family history of diseases and disorders. It is available for instant download in PDF format. You can then replace the logo using any PDF editor and add your business logo in its place.