Writing Medical Reports
Yes Winston, I am very opinionated about writing medical reports. Any document in medicine has a purpose for being created. Those purposes have evolved as well as the manner in which the information is generated. The types of reports have multiplied. My obsession with the creation of reports occurred as a result of a coping mechanism during my career’s evolution.
Once trained as a medical doctor, I was slow to make a decision on what to do with my career. My basic introduction to medicine had, by my own choice, been one of exposing myself to multiple fields. Once I selected internal medicine, it was shortly thereafter that I decided to concentrate my work in the field of lung diseases. With good fortune, ambition and fate, a short five years later I found myself in charge of the Pulmonary Function Laboratory at Walter Reed Army Medical Center.
My post graduate medical training at county, university, veteran and military institutions was designed to train me to be a medical doctor in the specialty of lung diseases. My knowledge of physiology was good for a pulmonologist, but almost superficial for my added job responsibilities. I set a goal to learn the field at a deeper level and was able to progress greatly over the years while I held that position.
On the practical side, tests were being done daily. Doctors from numerous specialties and clinics were ordering tests of lung functions and a report had to be generated for each. It was my responsibility to oversee the creation and quality of a large number of those reports. After leaving the military, I had similar responsibilities at a cardio-pulmonary specialty hospital for an additional 16 years. During the following 20 years, my reports were limited to interpreting sleep tests. Throughout my career, I have been responsible for an extremely large number of medical test reports.
In those early years I was progressively learning more about the details of my work. In my training and previous experience, I was exposed to reports which consisted of consolidated paragraphs with a signature at the end. As I learned more about the physiological aspects of our studies, I would segment portions of my reports to review each one in more detail. Over time, my reports became multiple, small descriptive paragraphs with many sections. At the end, I would summarize the results briefly.
As my knowledge increased, the report format evolved. I was separately analyzing and reporting each group of measured parameters. By doing so, their relationships were clearer and abnormal parameters were more readily identified. Constructing the report by simply separating each parameter analyzed, insured that the interpreting physician reviewed all the parameters and improved the communication of important results to the requesting physician.
Now, after 50 years working in this field, I am struck by how many respected doctors and physicians do not use such a format. Their single paragraph reports appear congested and chaotic when read, making it difficult to identify important numbers and features.
And yes Winston, our clinical reports, consults, progress notes and similar communications benefit from clear thinking and organization. It does not matter if the report is for other physicians, for your future reference, for insurance review or for the patients; a compartmental organized report demonstrates a thorough analytical analysis.
A medical report is a window on the organization and thinking of the professional who prepares it. A segmented, organized report communicates better and ensures attention is paid to each aspect of the subject. Continuous paragraphs of summarized facts suggest a chaotic, unorganized mind.
RGH Dec 2023
