sample medical report of patient with coma

How do you evaluate a comatose patient?

Introduction The evaluations of the comatose patients require a stepwise approach starting with a history, physical examination and laboratory evaluation. The causes of coma may be reversible when detected early.

How to write a medical report for a patient?

To write the report, it’s best to use proper wording that a reader may understand. Keep in mind that the people who may get a hold of the report may or may not be a part of the medical field. The report should contain a brief but understandable executive summary of the actual result.

How to avoid conflict between patient and patient medical report?

So, to avoid conflict, the patient medical report should be shown to the patients. HIPAA (Health Insurance Portability and Accountability Act) has been passed in the Congress of United States.

What should be included in a hospital report?

Hospital Medical Report Template – This type of medical report is designed for hospital use. Information includes patient’s name, ward, hospital name, medical consultant, discharge summary, the reason for admission and medical diagnosis, and past medical history.

How will you assess the patient with coma?

Cranial nerves V and VII can be assessed in comatose patients by testing corneal reflexes and by observing facial grimacing in response to noxious stimulation, such as supraorbital pressure. Cranial nerves IX and X can be assessed by testing the gag reflex, although this may be absent in 20% of normal subjects.

How do you find the history of an unconscious patient?

Opening the consultation.Wash your hands and don PPE if appropriate.Explain that you'd like to take a history from the patient.Gain consent to proceed with taking a history.Presenting complaint.Use open questioning to explore the patient's presenting complaint.History of presenting complaint.More items...•

What are the differential diagnosis of coma?

The differential diagnosis for the comatose patient is includes structural abnormality, seizure, encephalitis, metabolic derangements, and toxicologic etiologies. Identifying and treating the underlying pathology in a timely manner is critical for the patient's outcome.

How do you determine the level of consciousness in an unconscious patient?

The tool we use to assess the level of consciousness is the Glasgow Coma Scale (GCS). This tool is used at the bedside in conjunction with other clinical observations and it allows us to have a baseline and ongoing measurement of the level of consciousness (LOC) for our patients.

What are indicators that someone is coming out of a coma?

Signs of coming out of a coma include being able to keep their eyes open for longer and longer periods of time and being awakened from “sleep” easier—at first by pain (pinch), then by touch (like gently shaking of their shoulder), and finally by sound (calling their name).

How would you describe an unconscious person?

The person will be unresponsive (does not respond to activity, touch, sound, or other stimulation). The following symptoms may occur after a person has been unconscious: Amnesia for (not remembering) events before, during, and even after the period of unconsciousness. Confusion.

What part of the brain wakes you up from a coma?

We now know that there are collections of nerve cells in the lower part of the brain, called the brainstem, which are responsible for maintaining a waking state.

How do you approach an unconscious patient?

OverviewCheck the person's airway, breathing, and circulation.If you do not think there is a spinal injury, put the person in the recovery position: Position the person lying face up. Turn the person's face toward you. ... Keep the person warm until emergency medical help arrives.

What causes comatose?

Overview. Coma is a state of prolonged unconsciousness that can be caused by a variety of problems — traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, or even an underlying illness, such as diabetes or an infection. Coma is a medical emergency.

What are the 5 levels of consciousness?

There are five levels of consciousness; Conscious (sensing, perceiving, and choosing), Preconscious (memories that we can access), Unconscious ( memories that we can not access), Non-conscious ( bodily functions without sensation), and Subconscious ( “inner child,” self image formed in early childhood).

What are 4 levels of consciousness?

It is my observation that individuals and organizations move into and out of the four states of consciousness: unconscious unreality, conscious unreality, unconscious reality, and conscious reality. At differing points in time we live, move, and have our being in one of these levels of awareness.

How many stages of coma are there?

Three stages of coma DOC includes coma, the vegetative state (VS) and the minimally conscious state (MCS). These disorders (see sidebar at right for further information about each of these stages) are among the most misunderstood conditions in medicine.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physic...

Who Can Have Access to a Patient Medical Report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patien...

Is a Patient Medical Report a Legal Document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patie...

How many professional physicians are in the US?

As of September 2021, America has over 1,062, 205 professionally activity physicians. With that big number, it is no excuse that you cannot find an...

What are examples of medical records?

A medical report is just one example of a medical record. Other notable examples of medical records are the patient information leaflet, medical hi...

How can I get a medical report?

To get a medical report, you simply need to fill out a request form specifically for requesting medical records. You can submit the form to the doc...

What are the different types of medical reports?

Types of Medical Report Templates 1 Patient Medical Report Example – This is what you need if you’re looking for a generic medical report template. This medical report targets any patient with certain illnesses, ideal for clinic or hospital use. This contains needed information such as patient’s complete name, address, contact details, questions about medical status/history, and other related medical questions. 2 Hospital Medical Report Template – This type of medical report is designed for hospital use. Information includes patient’s name, ward, hospital name, medical consultant, discharge summary, the reason for admission and medical diagnosis, and past medical history. 3 Medical Examination Report Example – If you’re making medical reports intended for medical examinations, perhaps you might want to download this template for more convenience. This is a complete template that targets examination reports in a medical setting. 4 Medical Incident Report Template – This type of medical report focuses on any incident or accident that may happen within a medical setting. This is filled so that recording of details about incidents that occur at the medical facility will be tracked down and certain measures or sanctions will be implemented. 5 Medical Fitness Report Template – Making medical reports for fitness progress? This template is what you need. This aims at providing a thorough and complete report for medical fitness. The template contains information such as applicant’s name, address, license number, name of the hospital/clinic who conducted the report, and questions related to medical fitness.

Why is it important to update medical reports?

In every patient’s life, change always comes, may it be a changed name, address, medical progress, or a new health diagnosis and prescription.

What should be written down in a medical history?

Effects of alcohol, intellectual, emotional, psychiatric, and other drugs taken should be written down. Regardless if there are negative findings, it should also be included. Medical History. When writing a patient’s medical history, relevant medical conditions should be considered.

What are some examples of medical reports?

For some of the more in-depth and extensive examples, the different kinds of medical reports often include radiology reports, printable laboratory reports, and pathology reports.

Why is it important to use professional language in medical reports?

Use professional language and ensure that there is enough clarity to prevent any misunderstandings among all of the involved parties.

Is a medical report vague?

A medical report that comes off as vague is practically useless. For it to be valid and useful, the medical professional writing it must go into detail. With that said, use specific terms and provide particular comments and suggestions for the benefit of the report’s recipient.

Can you keep a copy of a medical report?

The creation of a medical report may dictate that you keep a separate but identical copy for yourself. The purpose of doing so is purely related to documentation. Also, in the event that the original medical report is somehow lost or tampered with, the patient can always turn back to you for references.