sample medical report of patient with epilepsy

What is the 2006 regional report on epilepsy?

This 2006 regional report is a modified and shortened version of the Global Campaign Against Epilepsy report. It describes the public health issues of epilepsy in North America and the need for a regional plan to address these issues.

How do I make decisions about epilepsy clinical trials?

Find epilepsy clinical trials that may be beneficial to your patients. The Agency for Health care Research and Quality (AHRQ) SHARE Approach is a five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.

What role do health care providers play in epilepsy care?

Health care providers play an essential role in recognizing, treating, and managing epilepsy.

How can I Manage my epilepsy on a daily basis?

People with epilepsy can benefit from learning skills and techniques that help them manage their disorder, its treatment, and its effects so that they can live full and satisfying lives. Physician support of patient self-management is a key component of effective chronic illness care.

How do you write a seizure report?

If known, when the seizure started, was the person awake or asleep? Was the person restless or did they cry out before the seizure started? Was there any trigger for the seizure (such as feeling tired or stressed)? What position were they in when the seizure happened or when they were found?

What should be documented when a patient has a seizure?

Documentation of initial medical history and physical should include the date of seizure onset, type and frequency of seizures, description of typical seizures, previous antiepileptic drugs (AEDs) used, and the date of the last seizure.

How do you assess a patient with epilepsy?

Your doctor may also suggest tests to detect brain abnormalities, such as:Electroencephalogram (EEG). ... High-density EEG . ... Computerized tomography (CT) scan. ... Magnetic resonance imaging (MRI). ... Functional MRI (f MRI ). ... Positron emission tomography (PET). ... Single-photon emission computerized tomography (SPECT).More items...•

How do you describe someone with epilepsy?

Saying it right. Some terms used in association with the condition are becoming less appropriate, due to their negative connotations or inaccuracy. While seizures may be referred to as 'epileptic', this is not an appropriate term for a person with the condition. The correct term is 'person with epilepsy'.

Where would you record information about a clients seizure?

A seizure diary is a good way of recording information about your epilepsy.

How do you record a seizure?

If you care for someone who is experiencing seizures, it can be very helpful to record them with a smartphone or video camera. This can then be shown to the person's doctor, which may help in diagnosis and treatment. During and/or after the seizure, ask the person some questions and record their responses to you.

What information is important to obtain when taking the history of a patient with seizures?

The following information should be obtained in the history: Record the patient's age. If a family history of seizures is noted, determine the clinical epilepsy syndrome of the affected family member. Ask about a history of any previous provoked seizure.

What is the initial assessment of a patient who may have experienced a seizure?

In the United States, most patients are initially evaluated in an emergency department and almost invariably undergo a CT head. MRI should be performed to identify the presence of an epileptogenic structural abnormality in patients with single unprovoked seizures.

What assessments are necessary for seizure?

Electroencephalography (EEG) is an important diagnostic test for patients presenting with seizures; the presence of interictal epileptiform discharges on EEG strongly supports a diagnosis of epileptic seizures.

What are the 4 types of epilepsy?

Experts now divide epilepsy into four basic types based on the seizures you're having:Generalized epilepsy.Focal epilepsy.Generalized and focal epilepsy.Unknown if generalized or focal epilepsy.

What are the warning signs of epilepsy?

Epilepsy: Seizure Triggers, Warning Signs, and SymptomsTemporary confusion—often described as a “fuzzy” feeling.A staring spell.Uncontrollable jerking movements of the arms and legs.Loss of consciousness or awareness.Psychic symptoms—out-of-body feelings or not feeling “in the moment”Memory lapses.

What is the main cause of epilepsy?

Epilepsy has no identifiable cause in about half the people with the condition. In the other half, the condition may be traced to various factors, including: Genetic influence. Some types of epilepsy, which are categorized by the type of seizure you experience or the part of the brain that is affected, run in families.

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...

What is a Patient Medical Report?

A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has.

What You Should Include in a Patient Medical Report

A patient medical report has some important elements that you should not forget. Include all these things and you can learn how to write a patient medical report.

Importance of a Patient Medical Report

The reason why a patient medical report is always given is because it is important. Here, you can know some of the importance of a patient medical report:

How to Write a Good Patient Medical Report

A doctor is a doctor. They are not writers. They can be caught in a difficulty on how to write a patient medical report. If this is the case, turn to this article and use these steps in making a patient medical report.

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 physicians, nurses, and doctors of medicine. It also includes the psychiatrists, pharmacists, midwives and other employees in the allied health.

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, patients’ access to the patient medical report is a must. It is their right to see their medical report. It is against the law not to show them their medical report.

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 patient is under your care. Thus, it can be used in court as an essential proof. So, keep a patient medical report because you may need it in the future.

What are the clinical difficulties of bipolar disorder?

Clinical difficulties have arisen in the diagnosis and treatment of his bipolar disorder. Management of his depressive episodes with simple selective serotonin reuptake inhibitors and mood stabilisers were either ineffective, or precipitated complicating adverse effects.

Does citalopram cause bipolar?

Persistent use of citalopram is likely to have triggered bipolar disorder, whilst quetiapine induced seizures. The clinical problems presented question the possibility that bipolar disorder; migraines and epilepsy may fall on the same spectrum of disorders.

Is bipolar disorder a co-morbidity?

Bipolar disorder; migraines and epilepsy are three prevalent conditions, of which little is understood about their pathophysiological processes. Co-morbidities often present between two of these conditions, but it is uncommon for all three to co-exist in a patient.

What is MEW network?

The Managing Epilepsy Well (MEW) Network is a group of academic Prevention Research Centers that conduct studies related to epilepsy self-management. Read how the MEW Network is improving health and quality of life for people with epilepsy through their research programs, and find resources#N#External#N#file_external#N#that you can use in your practice.

What is neurocysticercosis?

Neurocysticercosis is a leading preventable cause of epilepsy worldwide. This free online course educates clinicians about neurocysticercosis. Lessons include epidemiology, presentation, diagnosis, evaluation techniques, and management of patients. Continuing education credits are available at Neurocysticercosis: Diagnosis and Management of Patients Living in the United States.

What is the International League against Epilepsy?

The International League Against Epilepsy (ILAE) has revised its classification of seizures to make diagnosing and classifying seizures more accurate and easier. International League Against Epilepsy: A Practical Clinical Definition of Epilepsy. External.

What is the American Academy of Pediatrics?

The American Academy of Pediatrics National Coordinating Center for Epilepsy has tools for health care providers who care for children with epilepsy. Learn how drug management, diet management, social and emotional challenges, and medical homes play a role in the transition to adult care. Top of Page.

What is the NAEC?

The National Association of Epilepsy Centers (NAEC) is a nonprofit association that develops standards of care, accreditation for more than 230 member epilepsy centers across the United States, and provides informational resources to centers and individuals. ClinicalTrials.gov.

How does epilepsy benefit people?

People with epilepsy can benefit from learning skills and techniques that help them manage their disorder, its treatment, and its effects so that they can live full and satisfying lives. Physician support of patient self-management is a key component of effective chronic illness care. A patient is much more likely to participate in a self-management program with a recommendation from a health care professional.

What is a pearl?

PEARLS (Program to Encourage Active, Rewarding Lives) is an evidence-based self-management program designed to reduce depression and improve quality of life in adults with epilepsy. A mental health counselor provides 6 to 8 skill-building sessions that take place in a person with epilepsy’s home. The program uses a team-based approach, involving doctors, nurses, and social workers to help the individual overcome depression.

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.