Medical reports are formal documents that communicate clinical findings, diagnoses, and recommendations. Whether you're writing a consultation report for a referring physician, completing a disability evaluation, or documenting a diagnostic procedure, using standardized templates ensures completeness and professionalism.
This guide provides free medical report templates along with best practices for creating effective clinical documentation that meets professional and legal standards.
In This Guide
Types of Medical Reports
Different clinical situations require different types of medical reports. Understanding the purpose and audience helps you select the appropriate format and level of detail.
Clinical Reports
- Consultation report - Specialist evaluation and recommendations
- History & Physical (H&P) - Admission documentation
- Progress notes - Ongoing care documentation
- Discharge summary - Hospital stay summary
- Operative report - Surgical procedure documentation
Diagnostic Reports
- Radiology report - X-ray, CT, MRI interpretations
- Laboratory report - Lab test results and interpretation
- Pathology report - Tissue/biopsy analysis
- Cardiology report - EKG, echo, stress test results
- Pulmonary function - Spirometry and lung testing
Legal/Administrative Reports
- Independent Medical Evaluation (IME) - Third-party assessment
- Fitness-for-duty - Work capacity evaluation
- Disability evaluation - Functional capacity assessment
- Workers' comp report - Occupational injury documentation
- Medical-legal report - Expert witness documentation
Specialty Reports
- Mental health evaluation - Psychiatric assessment
- Neuropsychological report - Cognitive testing results
- Physical therapy evaluation - Functional assessment
- Occupational therapy - ADL and work capacity
- Speech-language evaluation - Communication assessment
Consultation Report Template
Consultation reports communicate specialist findings and recommendations to referring physicians. A well-organized consultation report facilitates care coordination and demonstrates the value of the specialty evaluation.
CONSULTATION REPORT
[Practice Name / Letterhead]
Patient: ________________
DOB: ________________
MRN: ________________
Date of Consult: ________________
Referring MD: ________________
Dictated: ________________
REASON FOR CONSULTATION
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
MEDICATIONS
PHYSICAL EXAMINATION
DIAGNOSTIC DATA REVIEWED
IMPRESSION
RECOMMENDATIONS
Thank you for this interesting referral. I will follow the patient as needed.
________________, MD
[Specialty] / [Credentials]
Consultation Report Best Practices
- Answer the question: Address the specific reason for referral clearly
- Be timely: Send report within 24-48 hours of evaluation
- List recommendations: Number your recommendations for clarity
- Follow-up plan: Specify if/when you'll see the patient again
- Copy distribution: Send to PCP and other relevant providers
Diagnostic Report Templates
Radiology Report Template
IMAGING REPORT
Date: ________________
Ordering MD: ________________
DOB: ________________
Accession #: ________________
CLINICAL INDICATION:
TECHNIQUE:
COMPARISON:
FINDINGS:
IMPRESSION:
Electronically signed by ________________, MD
Board Certified Radiologist
Laboratory Report Elements
Standard Lab Report Components
Header Information
- • Patient demographics
- • Specimen collection date/time
- • Ordering provider
- • Specimen type and source
- • Accession number
Results Section
- • Test name
- • Result value
- • Reference range
- • Flag (H/L/Critical)
- • Units of measurement
Independent Medical Evaluation Template
Independent Medical Evaluations (IMEs) are comprehensive assessments requested by insurance companies, attorneys, or employers. These reports require meticulous attention to objectivity, documentation, and opinion formation.
INDEPENDENT MEDICAL EVALUATION
Examinee: ________________
Date of Exam: ________________
Date of Injury: ________________
Claim #: ________________
Requesting Party: ________________
Employer: ________________
1. INTRODUCTION
State: purpose of evaluation, who requested it, documents reviewed, duration of examination, statement of objectivity.
2. RECORDS REVIEWED
List all medical records, imaging studies, and other documents reviewed with dates.
3. HISTORY
Detailed history including: mechanism of injury, symptoms, treatment to date, current complaints, pre-existing conditions, employment history.
4. PHYSICAL EXAMINATION
Comprehensive examination with specific measurements, range of motion testing, neurological exam, and any special tests.
5. DIAGNOSTIC STUDIES REVIEW
Interpretation of imaging and laboratory findings.
6. DIAGNOSES
List all relevant diagnoses with ICD-10 codes.
7. DISCUSSION & OPINIONS
Answer specific questions posed by requesting party. Address causation, MMI, impairment, work restrictions, and future medical care.
8. CONCLUSIONS
Summary of key findings and opinions.
I certify that the opinions expressed herein are my own and were formed to a reasonable degree of medical certainty.
________________, MD
IME Report Guidelines
- • Maintain objectivity - you are not the treating physician
- • Document all records reviewed with specific dates
- • Note any inconsistencies between history, exam, and records
- • Base opinions on objective findings, not examinee statements alone
- • Use AMA Guides for impairment ratings when applicable
- • Be prepared to testify regarding your opinions
Discharge Summary Template
Discharge summaries provide a comprehensive overview of a hospital stay for continuity of care. Joint Commission and CMS require specific elements to be included.
DISCHARGE SUMMARY
Patient: ________________
Admission Date: ________________
Discharge Date: ________________
Attending: ________________
Primary Dx: ________________
Disposition: ________________
ADMISSION DIAGNOSES
DISCHARGE DIAGNOSES
PROCEDURES PERFORMED
BRIEF HOSPITAL COURSE
CONDITION AT DISCHARGE
DISCHARGE MEDICATIONS
DISCHARGE INSTRUCTIONS
FOLLOW-UP APPOINTMENTS
Joint Commission Required Elements
- □ Reason for hospitalization
- □ Significant findings
- □ Procedures performed
- □ Treatments rendered
- □ Patient condition at discharge
- □ Patient/family instructions
- □ Discharge medications
- □ Follow-up appointments
- □ Pending test results
- □ Completed within 30 days
Report Writing Best Practices
Do
- ✓ Use clear, professional medical terminology
- ✓ Document both positive and pertinent negative findings
- ✓ Support conclusions with objective evidence
- ✓ Proofread for accuracy and completeness
- ✓ Sign with full credentials and date
- ✓ Complete reports in a timely manner
- ✓ Use templates for consistency
Don't
- ✗ Include personal opinions without evidence
- ✗ Use vague or non-specific language
- ✗ Copy-paste without reviewing for accuracy
- ✗ Leave sections blank or incomplete
- ✗ Include irrelevant information
- ✗ Use abbreviations without defining them
- ✗ Alter reports after signing
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Try Free for 7 DaysFrequently Asked Questions
What should be included in a medical report?
A complete medical report should include: patient identification, date of examination, referring physician (if applicable), chief complaint or reason for evaluation, relevant medical history, examination findings, diagnostic test results, clinical impression/diagnosis, recommendations, and provider signature with credentials. The specific format varies by report type.
What are the different types of medical reports?
Common types include: consultation reports, operative reports, discharge summaries, laboratory reports, diagnostic imaging reports (radiology, ultrasound, MRI), pathology reports, autopsy reports, independent medical evaluations (IME), fitness-for-duty reports, and specialty-specific reports (cardiology, pulmonology, etc.).
How do I write a professional medical report?
Write objectively using medical terminology accurately, organize information logically, include all relevant findings (both positive and negative), support conclusions with documented evidence, avoid speculation or personal opinions, proofread for accuracy, and sign with your full credentials. Use templates to ensure consistency.
What is the difference between a medical report and medical records?
Medical records are the complete documentation of a patient's healthcare interactions (notes, labs, imaging, etc.). A medical report is a formal summary document prepared for a specific purpose, such as a referral, insurance claim, legal proceeding, or disability evaluation. Reports synthesize information from records.
How long should a medical report be?
Length depends on purpose and complexity. A simple consultation report may be 1-2 pages, while an independent medical evaluation (IME) can be 10-30+ pages. Focus on completeness and clarity rather than length. Include all relevant information but avoid unnecessary repetition.
What are the legal requirements for medical reports?
Medical reports must be accurate, complete, and timely. They should be signed and dated by the authoring provider with credentials. Reports for legal purposes may require notarization or attestation. HIPAA requires authorization for most disclosures. Retain reports according to state medical record retention laws.
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