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Summary: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.
Format The date on which the report was prepared; The name of the person to whom the report is directed; The full name, date of birth and hospital unit record number of the subject. ... Identification of the author: This should include the practitioner's full name, practising address, current employment and qualifications.
Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication. If written correctly, notes will support the doctor about the correctness of treatment.
Include essential information Date and time. Name of the patient. Identification of the nurse who is writing the note. An overview or general description of the patient. Clinical assessment. Any incidents that occurred. Any changes noticed by the nurse (such as changes in the behavior, well-being, or emotional state)
Definitions of medical report. a report of the results of a medical examination of a patient. type of: report, study, written report. a written document describing the findings of some individual or group.