Medical Report: what is it and why is it important?
The Medical Report is a patient’s right and also a legal obligation that the doctor must comply with. Furthermore, it is essential because it details all the information necessary for the patient to undergo a medical examination safely.
Doctors use this document both to discharge the patient and to refer them to another health facility. And not only that, the Medical Report also plays an important role in legal proceedings.
Aware of the importance of the Medical Report, ProDoctor Software created this post to highlight the essential aspects in the preparation and particularities of this document. Follow the topics covered below:
- What is the Medical Report?
- Types of Medical Report
- Patient’s rights
- What does the Federal Council of Medicine say?
- How to prepare the Medical Report?
- Difference to Medical Report
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What is the Medical Report?
If you are just starting out in your medical career algeria mobile phone number list it is worth understanding what a Medical Report is. This is one of the essential documents that every doctor needs to know. Even for more experienced doctors, it is always good to remember the importance of this document.
Knowledge of Forensic Medicine is essential for all health professionals. Medical assistants must be familiar with and able to prepare all medical documents, regardless of their specialty.
The Medical Report has technical characteristics and, most of the time, patients use it to request benefits from the National Institute of Social Security – INSS . However, although it relates to the care the patient received, it should not be confused with a medical diagnosis.
Types of Medical Report
There are two main types of Medical Report. Let’s get to know them?
Forensic Medical Report
The first type of report we will present to you is the Forensic Medical Report .
The Forensic Medical Report is created to respond to requests from judicial authorities. In situations of police investigations, for example, the document must describe the medical examination in detail and directly answer the questions asked by the requester.
Medical Report for INSS
The second type is the Medical Report for INSS .
The INSS Medical Report is used daily by doctors who treat patients seeking a document that proves the treatment received. This report allows the patient to request benefits from the INSS.
|Read also: Why have management reports?
Patient’s rights
The Code of Medical Ethics, in Article 91 launch: eprescribing on ios – easier than ever guarantees the patient the right to request a Medical Report. The attending physician must provide it without charging additional fees.
The document includes a brief history of the case, without making any value judgments. In general, doctors provide this report at the time of discharge or when referring the patient to another professional or health unit.
Patients also often attach the Medical Report in legal proceedings, especially when seeking benefits such as sick pay and disability retirement.
The document must detail the information so that the medical examination can be carried out as requested.
What does the Federal Council of Medicine say?
According to the Federal Council of Medicine (CFM) , when requested by the patient or his/her lawyer, the doctor must provide a Medical Report with the necessary information. This includes diagnosis, test results, therapeutic conduct, prognosis and possible consequences.
The report should also specify the amount of rest required for the patient’s recovery. In addition, the doctor may suggest leave bulk lead retraining or retirement, but the final decision rests with the medical expert.
Practical examples of use:
- Request for social benefits: patients need detailed reports to justify their requests for sickness benefit or disability retirement from the INSS.
- Referral for other treatments: When a patient is transferred to another specialist, the report allows the new professional to understand the case history and continue care appropriately.
- Time off work: Medical reports recommending time off work must include the diagnosis, rest period, and necessary guidance for the employer and patient.
