Sample Medical Document

The sample medical document is an example of how health care facilities record the different activities pertaining to the patients. This is essentially used as medical records which contain specific patient history. The documents are important for both doctors and the patient. It is also used for reference for future medical issues. The medical document is a systematic documentation that carefully notes down the observations, administered medications and test results. The maintaining of such documents requires a high level of expertise and should be handled and documented by a licensed professional. The slightest error can cause both a health risk for the patient as well as legal issues for health institution.

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Sample Medical Document:

Sample Medical Document

Download Free Sample Medical Document

St. Matthew’s Hospital has documented the following observations for patient no. C123 under the care of Dr. Stevens:

Name of Patient: Rita Wilson

Date of admission: 1.1.2012

Age: 21 years

Complaint/History of Patient:

  • The patient has been having severe abdomen pains for the past 2 weeks since 15.12.2011. The pain is restricted to the appendix area and has not spread to any other region as of yet.
  • The patient also complains of blood found in her stools. There is no pain in the rectum area.

Exposure: The patient has not been exposed to any adverse element beyond the set routine.

Physical Exam:  An examination of the abdomen has been ordered.

Tests/Procedures: X-ray of the abdomen

Findings: Inflammation of the appendicitis has been spotted. Clinical correlation is advised.

Discussion: Surgery has been ordered for 19.1.2012

Medications: To be prescribed after surgery.

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