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GP training: Writing your first medical report

GPs are often called upon to write medical reports for patients. Dr Prashini Naidoo uses an example learning log to explain how to write a comprehensive and succinct medical report.

GPs need to be able to produce freestanding medical reports from which non-medically trained readers can glean the key issues of a case and reach a clear understanding of the GP's assessment and recommendations.

Below a reflective learning log looks at how a GP trainee approached writing their first medical report. After reading the reflection, please answer the questions that follow.  

Reflective learning log

Subject title: Learning to write my first medical report

What happened? The patient was a 20-year-old engineering student who suffered migraines. He recently started propanolol 40mg twice daily as prophylaxis. He kept forgetting the evening dose so I changed him to propanolol modified release 80mg once daily. At the end of the consultation, he asked for a letter to his university stating that he was unable to sit a recent exam because of migraine. It is very plausible that he did miss his exams because of migraine and I have no reason to distrust the patient.

What, if anything, happened subsequently? I said I would find out about providing a report and get back to him. I am aware that GPs write reports for patients. During a joint consultation, I observed my trainer respond to a request for a report on fitness to participate in a Himalayan expedition. However, I am not sure about the level of detail needed for this report (the Himalayan expedition provided a proforma and consent form). I spoke to the practice manager about report fees, did some online reading, and ran the draft report past my clinical supervisor.  

What did you learn? From my online reading, I learnd that it is good practice is obtain informed consent, preferably in writing. To do this, I should explain the scope, purpose and possible consequences of the report.

My report should be factual, should not express opinion and if I do not know the answer to a question, I should state so.

I created a report template for myself with the following headings:

  • I am writing this report for …. because ...
  • I met (name of patient) on {date}
  • (name of patient) said …...
  • The relevant past medical history is
  • (name of patient)'s response to treatment/interventions is
  • I advised the following current treatment regime.
  • I have or have not referred (name of patient) for a specialist opinion.
  • In response to your specific queries, my answers are summarised below.
  • The clinical justification for my comments and recommendations is based on {guidance}.
  • The patient tells me the impact of the symptoms is ...
  • I envisage a return to university/work within {time frame}, based on guidance from http://www.workingfit.co.uk/fitness-after-surgery
  • I advised the following {next steps}.
  • (name of patient) consents for this report to be sent.
  • My name, position and GMC number

What will you do differently in future? I could obtain the patient consent in surgery (I now know where the consent form is on the computer). I could (relatively quickly) generate the report using my template. My supervisor asked if I could present my template to a practice meeting and see if other GPs would be interested in using the template. She advised that if we could get the practice manager to import data under certain headings, the automation of data-entry could save even more time and effort. This could be a quality improvement initiative.

What further learning needs did you identify? From speaking to the practice manager, I became aware that I need to learn more about practice finances, particularly how general practice income is generated and shared.

Questions

Would the template-generated report above:

  1. Contain short numbered paragraphs and appropriate subheadings?
  2. State what opinion the doctor was asked to provide and details of the doctor's relevant knowledge and experience enabling them to comment on the issues.
  3. What (hospital) documentation the report writer considered?
  4. Whether the report writer undertook an examination or performed other investigation(s)?
  5. The report writer's personal details, name, current post, summary of previous experience, GMC registration number and whether they hold a current license to practice.
  6. What adjustments would you make to the trainee's report template?

Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest CSA Practice Cases for the MRCGP was published in January 2016.

Further reading

More articles and resources for GP trainees

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