Medical report and its importance

Overview

Medical report is the obligatory output of every clinical examination. It is an integral part of medical documentation of the physicians. It has an immense importance for securing continuity of provided medical care for its coordination with other institutions and providers of not only medical services, for limiting useless duplicities especially in indication of complementary examinations, but also for useless prescription of medical preparations and medical devices. The medical report is not a secret document to the patient, which should be wrapped in a sealed envelope except some particular respects. The medical report provides important and basic information about results of examination, recommendations and requirements for the following care not only in medical aspects, but also for the patient to take care of himself or herself. The composition of medical report and its delivery to the patient is obligatory of every specialist outpatient physician and the obligatory component of every clinical examination as far as it is allocated to reimbursement from the means of general medical insurance. The medical report if not only necessary for the patient visiting the registering doctor. The medical report has the form of an outpatient medical report or a report for the patient to be released from the hospital or transferred to another institution.

Keywords:
medical report – medical documentation – obligation to maintain medical documentation – obligation to write medical report during clinical examination of the patient – the form and content of medical records