Clinical template
Medical Report Template
A medical report is a letter to someone who was not in the room: a referring clinician, an insurer, an employer, or a school. It has a reader, a question, and an opinion grounded in the chart. It is not a SOAP with 'Dear Sir' glued on top.
Blank report letter
Copy this into Word or a Scribeberry letter template. Name the recipient and the question in the first paragraph. Keep diagnosis, function, and opinion in separate blocks so a claims adjudicator cannot mix them.
Medical report
[Date] [Recipient name, role, organization, address] Re: [patient initials or full name per privacy policy], DOB [date], your file [if any] Your reference / my chart: Dear [name / role]: Purpose of this report (who asked, what question): My relationship to the patient (MRP, one-visit, consultant) and date last seen: History relevant to the question: Examination / investigations I have personally reviewed: Diagnoses (working or established): Functional observations (what the person can and cannot do, with examples): Treatment and response to date: Opinion (answer the question asked; say if you cannot): Restrictions / limitations, with expected duration if known: Follow-up planned: I would be pleased to clarify in writing if needed. Yours sincerely, [Name, designation, college, clinic] [Contact]
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, insurer forms, or your own clinical judgment. Review every generated letter before it is sent.
Who the reader is
A consult reply to a family physician can use our jargon. An insurer wants diagnosis, function, and whether the person meets that insurer's definition of disability — which you may not be able to certify. An employer wants restrictions, not the diagnosis, unless the patient has authorized more. Schools want attendance and academic implications, not a full psychiatric formulation.
| Reader | They need | They do not need |
|---|---|---|
| Referring clinician | What you found, what you think, what you started, who owns follow-up | A recitation of the referral letter they already wrote |
| Insurer / disability | Relationship, dates, diagnosis, function, treatment, prognosis if you have one | Advocacy adjectives, or a claim that you have seen every file in the country |
| Employer / occupational health | Restrictions and expected review date | The diagnosis, unless consent is explicit |
| School / accessibility | Functional impact and recommended academic adjustments | Session-by-session psychotherapy content |
Get consent that matches the audience. A chart note does not automatically authorize a five-page letter to an employer. Fees for third-party reports are billed to the requestor or the patient, per clinic policy, not to the provincial health plan unless the schedule says otherwise.
Example 1 — short-term disability
Family physician to insurer
41-year-old man, Hamilton. Third-party report. Fictional.
28 August 2026 Attending physician statement — confidential Re: D.K., DOB 1985-01-09. Insurer file on the request form. Dear Adjudicator: I am Mr. K's family physician and have seen him since 2019. I last assessed him in person on 21 August 2026. You asked whether he is unable to perform his regular work as a city bus driver because of major depressive disorder, and for how long. History relevant to the question He presented in July 2026 with six weeks of low mood, anhedonia, insomnia, and impaired concentration. PHQ-9 was 19. No psychotic features. No suicidal plan at last visit; safety plan in the chart. He is not drinking. He has no prior psychiatric admissions. Examination / investigations Mental status 21 August: psychomotor slowing, restricted affect, cognition grossly intact, no current SI. TSH and CBC normal. I have not performed a workplace evaluation. Diagnoses Major depressive disorder, single episode, moderate, working diagnosis. Function He reports he cannot complete pre-trip checks without losing the sequence, and that he has twice pulled over for crying. I have not independently verified workplace performance. I have advised him not to drive a commercial vehicle until concentration and sleep improve. Treatment Sertraline started 50 mg daily 24 July, now 100 mg. Counselling referral sent. Off work as of 24 July. Opinion Based on my assessments, he is not currently fit for safety-sensitive driving work. I expect to review in four weeks. I cannot say whether he meets your policy's definition of total disability; that determination is yours. I have not seen him weekly, and I do not have occupational-therapy testing on file. Yours sincerely, [Name, CCFP, clinic]
Example 2 — specialist reply to GP
Neurology consult letter
62-year-old woman, Victoria. Outpatient consult. Fictional.
28 August 2026 Dr. [GP name] Re: L.S., DOB 1964-05-02. Thank you for referring. Dear Dr. [name]: I saw Ms. S on 27 August 2026 regarding six months of right-hand tremor and slower walking. You asked whether this is Parkinson disease and whether to start treatment. History Gradual rest tremor, worse at rest, better with use. Micrographia. No falls, no dream-enactment she is aware of, no antipsychotic exposure. Cognition subjectively unchanged. Meds as per your letter; I did not change them today. Examination Masked facies, 4–6 Hz rest tremor right hand, rigidity right>left, reduced arm swing. Pull test negative. MMSE 28/30. No cerebellar signs. BP 132/78 sitting, 128/76 standing. Opinion This is consistent with idiopathic Parkinson disease, Hoehn and Yahr 1–2. I discussed motor versus non-motor features and driving (no restriction today). I started levodopa/carbidopa 100/25 half-tablet TID with food, counselling for nausea and orthostasis. Follow-up I will see her in 10 weeks. Please continue usual primary care. I have not ordered MRI today; I will if red flags appear (early falls, poor levodopa response, gaze palsy). Yours sincerely, [Name, FRCPC Neurology]
Example 3 — fitness for modified work
To occupational health, diagnosis withheld
33-year-old warehouse worker, Edmonton. Patient authorized restrictions only. Fictional.
28 August 2026 Occupational Health, [employer] Re: employee file as provided. Patient authorized release of restrictions, not diagnoses. Dear Colleague: I assessed this employee on 28 August 2026 after an acute lumbar strain at work on 27 August. You asked what he can do on modified duties. Restrictions (7 days, then review) No lifting more than 10 kg. No repetitive bending. Sitting and standing as tolerated, with the ability to change position. No safety-sensitive driving until he is off sedating muscle relaxants (none prescribed today). He may do seated scanning and light sorting. He may take over-the-counter acetaminophen and ibuprofen as directed on the label if he has no contraindication. I have not certified a diagnosis to the employer. WSIB Form 8, if required, is a separate document. Please send him back on or before 4 September 2026, or sooner if leg weakness, saddle anesthesia, or urinary retention — those go to ED, not to the next clinic slot. Yours sincerely, [Name, clinic]
Mistakes that get letters returned
- Answering a disability question you were not asked, or refusing to answer the one you were.
- Copying the entire chart instead of the facts that support the opinion.
- Advocacy language ('this hardworking father deserves benefits') in place of function.
- Sending a diagnosis to an employer without consent.
- Dating the letter as if you examined the patient today when you last saw them in March.
- Unsigned PDF with no designation or college.
If the file is too thin for the opinion, say so. CRA, insurers, and WSIB would rather a short honest letter than a confident paragraph built on one visit. CMPA's third-party report material is worth reading before you fill a 12-page form from memory.
Draft the letter from the visit
Scribeberry can turn the encounter, or dictation, into a consult letter or third-party report in your template. Edit opinion language and consent, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a medical report?
A medical report is a letter that answers a question for a third party using facts from the health record: diagnoses, findings, function, and a clearly labelled opinion. It is separate from the encounter note in the chart.
Who can write a medical report in Canada?
The clinician who has the relevant relationship and scope: usually the MRP, a consultant, or an NP. Stay inside what you assessed. If you did not do a functional capacity evaluation, do not pretend you did.
Do I send the diagnosis to an employer?
Not unless the patient has authorized it. Occupational health usually needs restrictions, duration, and a review date. Insurers and referring clinicians typically need more clinical detail, under a consent that matches that audience.
Can Scribeberry write medical reports?
Yes. Use a letter template, record or dictate, and generate. You still check consent, recipient, and opinion wording before anything is sent or pushed to the EMR.
Templates
