Examination in the medical field is one of the strongest foundations of the field. Physical examination is the first step towards the better management of the patients and their ailments. Whenever a patient comes to the hospital, he comes with certain complaints. These complaints must be addressed. A technical way of addressing such problems starts with a detailed history taking of the patient.
An initial examination report is used for the purpose of maintaining a record of the patient. A patient when enters a hospital has always some significant findings which can only be detected by the initial examination conducted by the doctor. This examination is always reported and documented properly. This first-time examination carries a lot of importance and gives the foundation of a strong diagnosis and effective decision making for the management of the patient.
Initial examination report
Let’s have a look at a general initial examination report to know how it is filled and the important points to be mentioned in the initial report.
- Personal information of the patient is the most important section in any medical form. Patient’s full name, his age, gender, date of birth, contact number, emergency contact number and address, everything has to be mentioned in the information section. Not just for the future reference, this information is also one of the good ways to establish the identity of the patient.
- Similarly, a doctor’s name and relevant information along with his valid registration number have to be mentioned.
- After that, the patient’s ailment is mentioned. The duration of injury or illness is mentioned and then his presenting complaints are noted down.
- If the patient has got his insurance for medical cover, it is important to mention the details of his medical insurance as well. Some diseases take a lot of time, energy and resources which the insurance company has to bear. The hospital needs to mention that detail in their documents.
- After the general physical and systemic examination is done, the doctor may want to suggest some initial tests to help him reach the diagnosis of his problem. These tests are to be mentioned in the initial examination report.
- If the laboratory test, x-rays or ultrasound examination has already been done, reports of these tests are also mentioned. This also helps in getting a complete idea of the problem of the patient and how he was approached by the doctor.
- Initial management or prescription of the drugs by the physician are also mentioned in this form. If the patient was given further tests, that is also mentioned in the management section of the form. Otherwise, how the patient’s management plan has to be followed must be the content of this section.
- In the end, the doctor can add some additional notes or instructions if he feels necessary to mention. If the patient is going home, he may be advised certain things in the notes section.
- The doctor then signs the document and it is kept safe with the other record of the patient. This report can be used for future reference.