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Medical Reports Medical History Physical Examination Physician Orders Progress Notes Laboratory Reports - Radiology Reports Other Diagnostic Procedures Medication Sheet Consent Forms Consultation Reports CONFIDENTIALITY Confidentiality and privacy are terms often used interchangeably in reference to medical data . Privacy is the right to be left alone. Confidentiality means keeping secret. Medical Confidentiality is concerned with the restrictive use of information obtained from and about a patient. CONFIDENTIALITY CONSENT TO RELEASING INFORMATION Informed consent means that the patient is aware, in a general way, what information will be released and use that will be made of the information Written authorization of releasing information Policies and procedures of releasing information CONFIDENTIALITY Methods of Releasing Information Direct access Abstracting Information Oral release Photocopying Fax Transmission Mail Medical Reports Dr. Nasser Al - Jarallah Medical Reports There are many different types of medical reports, written for different reasons. If you work in the healthcare industry, you must often write medical reports. Medical Reports You also may need to know how to write a medical report if you care for a sick person in the home. The information in the report must be timely and confidential so that it can serve as a legal document if necessary Medical Reports Step1 Know that a common type of medical report is written using the SOAP method. This stands for Subjective Objective Assessment Plan. The subjective part of the report tells what the patient says about his symptoms in his own words. The objective part of the report details what you see and hear when you observe the patient. Medical Reports Step2 Assess the patient after observing his problems and symptoms. When you write a medical report, this is where the analysis of the condition is noted. Tell what conclusions can be drawn to assist the diagnosis. Document all the facts accurately