Medical Report Template with Examples

Shine Colcol

March 27, 2025•16 min read

Fact checked by Dr. Ben Condon

Template

Medical Report Template

This medical report template is used to document a patient’s medical treatment based on information found in their medical record or clinical exam. It is built according to the guidance provided by the Royal Australian College of General Practitioners (RACGP). Using Heidi, the AI medical scribe for all clinicians, to fill out this template will allow you to:

Quickly, accurately, and completely capture patient data and insurance claim information
Consistently document details with a uniform structure and easily compare a patient’s medical reports
Meet legal documentation standards and ensure confidential data storage

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See Sample PDF

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What is a Medical Report Template?

A medical report template is a structured assessment of a physician’s subjective and objective findings on a patient. Filled-out reports typically contain the patient’s information, insurance claim details, GP credentials, chief complaint, past medical history, vital signs, patient condition, findings, and prognosis.

Medical reports differ from medical charts by focusing on the patient’s current condition as opposed to being a continuous record.

In this article, we’ll discuss the importance of using medical report templates, their different uses, and how physicians can write medical reports effortlessly.

The Impact of Medical Report Templates in Healthcare

Using well-structured medical report templates gives a standardized format to ensure consistency and clarity in a patient’s records. In fact, using standardized report templates has improved the following:

Comprehensiveness of rectal cancer staging MRI reports with the total number of satisfactory reports increased from 38.5% to 70.4%.
Communication between healthcare providers by having easier-to-organize information that also allows for better quality control.
Reduced turnaround times by about 20.7 minutes.

These improvements came as a result of transitioning from lengthy free-text reports to predefined formats.

Additionally, medical professionals can opt to standardize the adoption of medical report templates to improve document quality. This helps maintain uniformity in documentation while minimizing errors and enhancing report accuracy.

Different Uses of Medical Report Templates

Healthcare professionals use medical report templates to effectively assess the findings of different examinations. These assessments are then used for different purposes which we’ve listed below:

1. Insurance and Billing

Different insurance providers use different medical report templates to determine the amount of coverage and support they’ll provide. For example, Australian providers such as WorkCover and TAC require the use of specific report templates to ensure consistent and accurate assessments. These templates are the following:

WorkSafe Victoria Independent Medical Examination Report Template, while WorkSafe Queensland does not require a single template format as long as the following key areas are addressed: 1) Diagnosis and present condition; 2) Patient treatment and rehabilitation; and 3) Work capacity assessment.
TAC uses the South Australian CTP Insurance Claims Medical Certificate
Life and health insurance providers use the Personal Medical Attendant’s Report or Brief Medical Report
Super SA uses a Medical Practitioner Report

Certain providers may require patients to provide periodic reports to verify the patient’s ongoing condition and justify the continued coverage. This is more common when a patient is undergoing specialized treatment or long-term care. Failing to submit regular reports could result in the provider reducing funding and support or discontinuing the coverage.

2. Medical Certificates

Medical practitioners issue medical certificates using information gleaned from medical reports. Because the reports provide structured, official, and legally valid documentation on the person’s condition, they will effectively serve as supporting evidence, making the certificate itself defensible in court.

3. Forensic and Legal

Medical reports ensure the accurate documentation of a patient’s injuries, the cause of their death, and all forensic findings. Besides personal injury claims, these templates are also used in medical-legal cases and autopsies.

These reports document injuries, medical conditions and cause of death, provide expert opinions, support evidence for lawsuits and criminal cases, and assess an individual’s fitness for legal matters.

4. Telehealth Consultations

Medical reports are also used in the telehealth industry as more and more people are now open to virtual consults. Using standardized report templates helps clinicians to accurately and consistently record patient information while ensuring compliance with relevant regulations. However, such templates still require clinicians to spend hours writing a report after a consultation.

Telehealth organizations can opt to utilize AI medical scribes to cut down on the time spent writing reports. My Emergency Doctor, a telehealth organization with more than 100 clinicians worldwide, adopted the Heidi AI medical scribe and saw reduced documentation times and an average of three minutes saved per call for FACEMs.

Tatiana Lowe, Medical Director and FACEM at MED, mentioned that medical summaries produced by Heidi “filters out all the unnecessary details and includes clear plans and patient instructions.” This effectively streamlines the documentation process as the scribe transcribes in real-time during a consult. Watch the video below to see Heidi in action:

What is the Standard Medical Report Format?

A standard medical report format ensures that all relevant details (administrative, clinical, and legal) are recorded accurately for communication between clinicians, insurers, and other authorized organizations. While formats vary by region or purpose, most medical reports follow a similar structure:

Administrative Details
Clinician Credentials and Declaration
Purpose and Scope of the Report
Subjective Findings (Patient-Reported Information)
Objective Findings (Clinician-Observed Information)
Assessment or Diagnosis
Management Plan and Recommendations
Certification and Signature

How to Write a Medical Report Using a Template with Examples

Writing a medical report largely revolves around following a set report format and accurately filling it out to comply with insurance providers’ and other organizations’ requirements. These formats will vary but will all serve the same purpose of producing complete and accurate records. Below is a sample template derived from the Royal Australian College of General Practitioners’ template.

Administrative Details

Date of request: March 25, 2025
Received from: Horizon Insurance Group
Claim number: 98765432
Patient name: Michael Ramirez
Patient date of birth: July 22, 1980
Practice name: Westside Family Clinic
GP name: Dr. Samantha Lewis
GP credentials: MD, General Practitioner

General Practitioner Credentials

Report Prepared By:

This report has been prepared by Dr. Samantha Lewis, an MD with 12 years of experience in general practice. I have been treating Michael Ramirez since 2016, and I am his usual GP.

Purpose and Scope:

This report has been prepared at the request of Horizon Insurance Group to provide medical information regarding Michael Ramirez’s chronic lower back pain. The report is based on medical records and includes details of the patient’s condition, treatment, investigations, and referrals.

There may be some gaps in the medical record where relevant.

Subjective Findings

Demographic and Contextual Factors:

Michael Ramirez is a 44-year-old male who works as a warehouse supervisor.
His job involves prolonged standing and occasional heavy lifting, which he reports has contributed to his condition.

Symptoms (Patient-Reported):

Persistent lower back pain.
Morning stiffness.
Occasional radiating pain down the left leg.
Reports moderate improvement with physical therapy but continues to experience pain flare-ups.

Impact on Lifestyle:

Time Off Work: Required occasional medical leave, totaling approximately 8 weeks since 2019.
Functional Limitations: Reports difficulty with prolonged standing and lifting.
Workplace Adjustments: The employer has implemented accommodations based on reported difficulties.

Objective Findings

Medical History & Diagnosis:

First presented with lower back pain in May 2019.
Diagnosed with chronic lower back pain in September 2019.

Test/Investigation Results:

MRI (October 2019): Mild disc herniation at L4-L5.
X-ray (January 2022): Early signs of spondylosis.

Medical Management to Date:

Medications: Naproxen 500mg twice daily and muscle relaxants (Tizanidine 2mg at night).
Referrals: Orthopedic specialist (October 2019) and Physiotherapist (November 2019 - ongoing).
Hospitalizations: None related to this condition.
Procedures/Therapies: Physical therapy three times a week and epidural steroid injections (twice in 2021).

Ongoing/Planned Management:

Medications: Continue Naproxen and Tizanidine as needed.
Referrals: Follow-up with an orthopedic specialist in four months.
Hospitalizations/Procedures/Therapies: Continue physical therapy, with potential for additional steroid injections if pain persists.

Prognosis:

Michael Ramirez’s condition is chronic but manageable with ongoing treatment.
If symptoms worsen, further interventions such as surgery may be considered.

Medical Opinion / Response to Requested Questions:

Michael Ramirez’s chronic lower back pain significantly impacts his ability to perform physical tasks. He will require continued treatment and work accommodations as well as long-term pain management strategies for the prognosis to remain stable.

I confirm that the information in the above report is true and correct. This report will not be altered but I will provide a supplementary report with more details should it be deemed necessary.

Certification and Signature

GP’s Name and Signature: Dr. Samantha Lewis
GP’s Phone Number: (555) 987-6543
GP’s Email Address: slewis@westsideclinic.com
Date: March 25, 2025

Medical Report Template Example

In addition to the RACGP’s sample template, Heidi also provides a free sample template you can use. Here’s Heidi’s free sample Medical Report template in PDF and Google Doc form:

Because there are many different template formats to use according to the requirements of different providers and organizations, you should consider streamlining the process through a medical scribe.

Effortlessly Write Medical Reports with Heidi

Heidi Health’s AI medical scribe effectively simplifies the documentation process as it transcribes information in real-time and fills out the fields of a template you’ve set up.

Transcribe – Using your computer or mobile device, press “Start transcribing” to start transcribing the conversation. You can also upload your own notes to handle any report backlogs you might have.
Customize – Indicate or select a medical report template to use using any information recorded by Heidi and it will auto-populate the template to produce a complete report.
Transform – Review the completed report to see if the scribe has missed any crucial details from the conversation and ask Heidi to include any missing details into the report. You can also ask Heidi to use another template if you accidentally used the wrong template for a consult. Additionally, you can upload your own custom template to use.

Heidi is actively assisting clinicians worldwide handle more than 1 million patient consults per week all while complying with relevant region-specific regulatory requirements for data privacy. It is an ISO-certified and APPs and NZ IPPs-compliant AI scribe that can effectively improve a clinician’s workflow.

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Free Medical Report Template Samples

Patient Medical Report Template

A patient medical report template provides a comprehensive overview of a patient’s current condition, medical history, and current treatment plan. This template is commonly used for general medication, referrals to specialists, insurance claims, and legal purposes.

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Medical Narrative Report Template

A medical narrative report template is used to offer a detailed and written account of a patient’s medical condition, the progress of their treatment, or a specific medical event. This is used for a worker’s legal disputes, compensation cases, or personal injury claims, adhering to WorkSafe Queensland requirements.

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Medical Diagnosis Report Template

A medical diagnosis report template focuses on a patient’s diagnosis based on their test results and medical evaluation. Physicians use this to provide a diagnosis to the patient, other specialists, or insurance providers for medical leaves, disability assessments, or insurance claims.

View Template

FAQs About Medical Report Templates

What is an example of a medical report from a doctor?

Here is a brief example of a narrative medical report: "Dr. Sarah Cole, MD, General Practitioner at Southern Hospital, reports that John Smith (born July 1, 1980) has had chronic lower back pain for three years, worsening in the past six months. Physiotherapy and NSAIDs offered limited relief. Examination showed lumbar tenderness and reduced range of motion with stable vitals and no neurological deficits. MRI revealed mild L4-L5 disc degeneration without nerve impingement. The patient was diagnosed with chronic lower back pain secondary to degenerative disc disease and will continue conservative management with adjusted pain medication. A specialist referral was made, and follow-up is planned in six weeks or sooner if symptoms worsen."

What is the best format for a medical report template?

While there is no single format that is considered to be the best format, RACGP’s sample template can serve as a base template for clinicians to use according to their needs. They can modify this template to include or exclude certain information depending on what the report will be used for.

Are medical report templates legally required?

There is no specific legal requirement to use specific medical report templates but insurance providers may deny claims when a report does not follow their required formats.

How can I create my own medical report template?

With Heiid, you can create your own medical report template by going to “Template library,” pressing or left-clicking on “Create template,” and then either creating a new template from scratch or modifying an existing template for your own use. You can paste a template you copied and modify it according to your specific needs. Review our guide for creating custom templates for more information.

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