To write a medical diagnosis, report the patient's history and the results of tests that occurred during the examination, explains Weill Cornell Medical College. Report data received from the laboratory, and complete a summary and an assessment. An outlined plan for further testing and treatment should end the report.
The history report should include the patient's primary symptom and history relating to the symptom as well as the patient's past medical history, social history and family medical history, according to Weill Cornell Medical College.
The physical examination report must include the patient's basic vital signs and the status of the head, ears, eyes, nose and throat, reports Weill Cornell Medical College. Report the results of the rest of the examination, including findings related to the neck, chest, abdomen, gender-specific regions and extremities.
In the third section, report the basic data received from laboratory tests, says Weill Cornell Medical College. Next, summarize the case with accurate yet brief statements in three to five sentences. The assessment that follows must include the diagnosis and how the top two most influential symptoms relate to the diagnosis and the patient's specific case. After discussing the diagnosis, construct a plan for action that includes recommendations for further testing, procedures or therapy