Medical report template

A medical report is a formal summary written for someone outside the treating team: an employer's health service, another clinician, a school, or a patient who asked for one. It must be factual, sourced and limited to what was asked. Here is a template, an invented example, common faults, and how ClearPass drafts a report from a note.

Start free — 7 days, no card See pricing

What sets a report apart from a clinical note

A clinical note is written for the chart and uses clinical shorthand. A report is written for a reader who may not be a clinician and who will rely on it for a decision. It should be in full sentences, explain terms, and separate fact from opinion.

Start by stating who asked for the report, for what purpose, and that the patient consented to its release. List the sources you used: your own assessments with dates, previous notes, letters and results. Then set out the presenting problem, history, examination and investigation findings, diagnosis, treatment given and current status. Give an opinion on prognosis or capacity for work only if it was requested and you have the basis for it; if it is outside your expertise, say so.

Blank medical report

Template

MEDICAL REPORT
Prepared by: [name, role, clinic]
Requested by: [ ]   Purpose: [ ]
Patient consent to release: obtained on [date]
Patient: [identifiers as required]

1. Sources of information
2. Presenting problem
3. Relevant history
4. Examination findings (with dates)
5. Investigations (with dates and results)
6. Diagnosis
7. Treatment given
8. Current status
9. Opinion (only on questions asked)
10. Limitations of this report

I confirm the facts above are true to the best of my knowledge.
[Signature]   Date: [ ]

Copy and adapt. Headings are a common layout, not a regulatory standard.

Filled example: shoulder injury report

Example

Requested by: the patient, for their employer's occupational health service. Purpose: current status and fitness for manual duties. Consent to release obtained.

1. Sources: my assessments at three visits over 10 weeks; ultrasound report; physiotherapy summary.
2. Presenting problem: pain and weakness in the right shoulder after lifting a heavy box at work.
3. History: 41-year-old right-handed warehouse worker. Onset of pain at the time of lifting; unable to raise the arm above shoulder height for the first 2 weeks. No previous shoulder problems.
4. Examination: at first visit, painful arc between 70 and 120 degrees, weakness on resisted abduction. At the latest visit, full range with mild pain at end range, strength near normal.
5. Investigations: ultrasound showed supraspinatus tendinopathy with a small partial-thickness tear, no full-thickness tear.
6. Diagnosis: right rotator cuff tendinopathy with small partial tear.
7. Treatment: analgesia, 8 weeks of physiotherapy, modified duties.
8. Current status: much improved; able to lift light loads and work at desk height.
9. Opinion: fit for light manual duties now. Overhead lifting and loads above a moderate weight should be avoided for a further 6 weeks, then reviewed.
10. Limitations: I have not assessed the workplace.

Invented example for illustration. Not a real patient.

Faults in medical reports

No statement of who asked for the report and why, so the scope is unclear.
Opinion presented as fact, or opinion given on questions nobody asked.
Undated findings, so the reader cannot tell old from current.
Clinical abbreviations a non-clinical reader cannot follow.
Releasing information the patient did not consent to share.

How ClearPass drafts a medical report

In Documents, choose Medical report. ClearPass writes a formal report from the note you select or paste: presenting problem, relevant history, examination and investigation findings, diagnosis, treatment given and current status. Use the extra detail box to say who the report is for and what it should address, for example for occupational health, current fitness for manual work.

A report often draws on several visits. ClearPass writes from the text you give it, so paste the relevant parts of each note from History, or a summary you type, into the note box first. It adds nothing clinical that the text does not say. The sources list, consent line and limitations are yours to confirm, and so is any opinion. Read the whole draft, edit it in place, and sign only once it says exactly what you are prepared to stand behind. For shorter documents see the sick note template or fitness letter template.

What ClearPass does not do

It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
It is not a medical device and does not make clinical decisions. It is a documentation aid.
It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Do I need the patient's consent to write a medical report for a third party?

In most settings, yes, for the release of their information. Check the rules and policies that apply where you practise.

Should a report include everything in the chart?

No. Include what is relevant to the questions asked. Unrelated history should stay out unless the patient agrees and it matters.

Can ClearPass combine several notes into one report?

Paste the relevant notes together into the note box and choose Medical report. It works from the text you provide.

What does ClearPass cost?

The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.

Try it on your next clinic day

The full product for 7 days, with no card and no automatic charge. Then $78 a month or $858 a year. Pricing details.

Start free — 7 days, no card