Medical Report Outline Template
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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]
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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