Writing a Medical Report: How to Create a Professional Doctor’s Letter

The doctor’s letter (medical report) is a key communication tool in everyday medical practice. It ensures that all healthcare professionals involved are informed about a patient’s current health status. At the same time, writing such a report can be challenging in a busy clinical or practice setting.

In this article, we explain what a medical report should contain and provide proven wording examples as well as practical tips to help you write a doctor’s letter quickly and efficiently.

What Is a Medical Report?

A medical report (also referred to as a discharge letter or medical letter) summarises medically relevant information about a patient’s health status, diagnostic findings, treatment and, where applicable, recommendations for further care.

It is usually written after an inpatient stay or specialist outpatient treatment and serves to support ongoing medical care. The report is primarily addressed to physicians involved in further treatment, such as general practitioners or other specialists, but may also be directed to the patient themselves.

Structure of a Medical Report – What It Should Include

A clearly structured medical report allows for quick orientation and facilitates efficient information exchange with colleagues involved in further care. Below, we outline how to structure your medical report effectively and what content should be included in each section.

1. Header and Sender Details

The header contains the most important information about your practice or institution. Typical elements include:

• Name of the practice or institution
• Medical specialty
• Address
• Telephone number and email address

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2. Recipient and Patient Information

Directly below the header, include details of the receiving practice or person as well as the patient’s information:

• Name and address of the recipient
• Patient’s name, date of birth and, if applicable, insurance number
• Internal identifiers such as case or patient ID (if relevant)

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3. Subject Line

The subject line should clearly and concisely state the reason for the report. It enables rapid classification of the content and should be as specific as possible. Avoid vague terms such as “Medical Report” without further explanation. Examples include:

• “Medical report following outpatient consultation for unexplained abdominal pain”
• “Discharge summary after inpatient treatment for decompensated heart failure”

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4. Treatment Period

Specify the period during which the treatment took place. For inpatient cases, this includes the admission and discharge dates; for outpatient care, the individual appointments or the overall treatment period. This temporal context helps recipients correctly integrate the report into the patient’s medical history.

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5. Medical History (Anamnesis)

In this section, describe the reason for presentation as well as medically relevant pre-existing conditions or accompanying circumstances. Summarise the patient’s reported symptoms and supplement them with known diagnoses, previous treatments and, where relevant, social or care-related factors that may influence treatment. Focus on key information and avoid unnecessary detail.

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6. Findings

Here, list the most important clinical findings and examination results. This includes physical examinations, laboratory values, diagnostic procedures and imaging studies. Structure the results thematically and prioritise them according to relevance for the diagnosis. Detailed raw data or complete laboratory lists are not required; focus on the essentials and briefly comment on abnormal findings if necessary.

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7. Diagnoses

State the final diagnoses in this section. Begin with the primary diagnosis, followed by any secondary or comorbid diagnoses. Use clear and unambiguous terminology and avoid vague wording. If a diagnosis is not yet confirmed, clearly indicate it as a suspected diagnosis. Chronic conditions should also be listed if they are relevant to the current treatment.

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8. Treatment and Clinical Course

Describe the therapeutic measures carried out during the treatment period and how the patient’s condition developed in response. This includes pharmacological treatments, surgical or invasive procedures, physical therapies and follow-up assessments. Document relevant changes such as improvement, newly occurring symptoms or side effects. Complications or treatment discontinuations should also be noted.

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9. Epikrisis (Clinical Summary)

The epikrisis is the central evaluative section of the medical report. It brings together medical history, findings, diagnoses and clinical course into a coherent overall assessment. Here, you should explain:

• How the diagnosis was established
• Which therapy was chosen and why
• How the patient responded to treatment
• Which conclusions are important for further care

The epikrisis may be interpretative in nature and represents the medical “common thread” of the case. In uncomplicated cases, it may be brief and combined with the clinical course section, but should still be clearly identifiable as such.

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10. Medication Plan

Provide a complete list of the current medication at discharge or at the time of the report, including:

• Active ingredient (and, if applicable, brand name)
• Dosage and frequency
• Timing and duration of administration
• Notes on side effects or interactions (if relevant)

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11. Recommendations for Further Treatment

Clearly outline how care should proceed after discharge or the last consultation. This may include:

• Continuation or adjustment of medication
• Recommended follow-up intervals
• Further diagnostic measures or referrals to other specialties
• Information on physical capacity or ability to work
• Rehabilitation or care-related measures, if applicable

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12. Signature and Author Details

Conclude the medical report with the name, role and signature of the responsible physician. Where legally required or customary in clinical settings, a practice stamp or qualified electronic signature may be added.

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Formal and Linguistic Requirements for Medical Reports

A professional medical report must meet not only content-related but also formal and linguistic standards. The most important guidelines include:

• Objective and factual tone: Avoid evaluative or colloquial language. Stick to verifiable facts when describing findings and clinical course.
• Medically accurate yet clear: Use medical terminology where appropriate, but ensure the text remains understandable for recipients from other specialties.
• Clear and concise sentences: Long, complex sentences hinder readability. Aim for one clear idea per sentence.
• Consistent layout: Use a readable font size (e.g. 11–12 pt), clear subheadings and sufficient line spacing.
• Data protection: Patient-related information may only be shared with authorised recipients. Transmission should be secure and encrypted (e.g. via KIM or delivery through the patient).
• Date and signature: As a medico-legal document, the report must include complete information about the issuing physician, including name, title, role and date of creation.

Writing Medical Reports with AI? ETERNO Cloud Makes It Possible

Writing medical reports is one of the most time-consuming tasks in daily practice. AI-supported features can significantly reduce this workload. With AmbientAI transcription, ETERNO Cloud offers an intuitive solution that automatically documents patient consultations and converts medically relevant information into a structured summary.Speech recognition for medical report writing substantially simplifies the subsequent drafting process.

Additional AI Features of ETERNO Cloud

As a smart AI-powered practice management system, ETERNO Cloud offers many additional modules to further streamline daily workflows:

• CareView: An AI practice dashboard with real-time insights into appointments, patient data, diagnoses, communication channels and billing-relevant KPIs.
• VisitAI: AI-based no-show prediction to forecast appointment adherence, reduce cancellations and optimise scheduling.
• HelloCare: Your AI-powered online reception for handling digital requests, from prescription renewals and appointment changes to patient enquiries.
• CareFlow: Automates digital check-in and supports front-desk staff, including card reading, document capture and patient routing.

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ETERNO Cloud – The All-in-One Solution for Modern Medical Practices

ETERNO Cloud combines all essential practice functions in a cloud-based system and offers numerous advantages:

• Location-independent access: Full functionality on any internet-enabled device, including mobile and home office use.
• GDPR-compliant: Highest security standards with data storage in certified German data centres.
• No local server hardware required: A fully cloud-based solution eliminates acquisition and maintenance costs for in-house servers.
• Intuitive user interface: Clear navigation, minimal onboarding time and fast access to all features.
• Rapid implementation: Go live within just 30 days, with full support at every step.

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Frequently Asked Questions About Writing Medical Reports

Am I legally required to write a medical report?

Yes, in certain situations writing a medical report is legally required. Under § 630f of the German Civil Code (BGB), physicians are obliged to document all treatment-related measures and their outcomes in the patient record.

How do I write a proper medical report?

A good medical report is medically precise, clearly structured and professionally comprehensible. It should be written in an objective tone, present relevant information in a structured manner and support efficient continuation of care. Formal aspects such as clear structure, consistent layout and understandable language are equally important.

What should a medical report look like?

Physicians can use the following structure as a template:

• Header with sender details
• Recipient and patient information
• Subject line stating the reason for the report
• Treatment period
• Medical history
• Findings and diagnostics
• Diagnoses
• Epikrisis
• Treatment and clinical course
• Recommendations for further care
• Medication plan
• Signature with name and role

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Which Phrases Can Be Used in a Medical Report?

To help you get started, here are some commonly used wording examples that can be adapted to individual cases:

• “The patient presented with symptoms of [symptoms] persisting for [period of time].”
• “A long-standing history of [condition] is noted as a risk factor.”
• “Symptoms had been present for [period] and showed a [progressive/stable] course.”
• “Additional symptoms included [further symptoms].”
• “Based on clinical presentation and [findings], the diagnosis of [diagnosis] was established.”
• “The diagnostic/therapeutic measures performed confirmed our suspected diagnosis of [diagnosis].”
• “Differential diagnoses such as [alternative diagnosis] were excluded by [examination].”
• “At discharge, the patient was [asymptomatic/improved/stable].”