A Medical Report Letter From Doctor is an essential medical document in the Nigerian healthcare system, regulated under the Medical and Dental Practitioners Act and the National Health Act 2014. This document type is commonly required when formal medical documentation is needed to verify a patient's health status, support insurance claims, validate medical leave, or provide evidence in legal proceedings. The letter must include comprehensive medical information while adhering to patient confidentiality requirements under Nigerian law. It serves as an official record of a patient's medical condition, containing detailed clinical findings, diagnosis, treatment plans, and professional medical opinions. The document's format and content must comply with the standards set by the Medical and Dental Council of Nigeria and should be prepared only by licensed medical practitioners.
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1. Letterhead and Date: Doctor's/Hospital's official letterhead including medical license number, contact information, and date of report
2. Patient Identification: Full name, date of birth, gender, hospital/patient ID number, and contact details of the patient
3. Report Purpose: Clear statement of why the medical report is being written and who requested it
4. Clinical History: Relevant medical history, including presenting complaints and duration of symptoms
5. Physical Examination: Findings from physical examination and vital signs
6. Diagnosis: Clear statement of the medical diagnosis or conditions identified
7. Treatment Summary: Overview of treatments provided or recommended
8. Current Status: Patient's current medical condition and prognosis
9. Conclusion: Professional medical opinion and recommendations
10. Authentication: Doctor's signature, name, qualifications, and medical registration number
1. Laboratory Results: Include when relevant diagnostic tests have been performed
2. Specialist Referrals: Include when patient has been referred to other healthcare providers
3. Work Capacity Statement: Include when report is for employment purposes
4. Medication List: Include when current medications are relevant to the report's purpose
5. Future Treatment Plan: Include when ongoing treatment is required
6. Risk Assessment: Include when report is for insurance or legal purposes
7. Functional Capacity: Include when report relates to disability or rehabilitation assessment
1. Laboratory Reports: Copies of relevant test results and medical investigations
2. Imaging Reports: Copies of X-rays, MRI, CT scan reports if applicable
3. Previous Medical Records: Relevant past medical records that support current findings
4. Specialist Reports: Attached reports from referred specialists if applicable
5. Photographs: Medical photographs if relevant (e.g., for surgical or dermatological cases)
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