Clinical Report Writing

Comprehensive clinical documentation for healthcare, research, and regulatory compliance: case reports (CARE guidelines), diagnostic reports, clinical trial reports, and patient documentation.

Key Benefits

Four major report types: case reports, diagnostic reports, trial reports, patient documentation
CARE guidelines compliance for journal publication
Regulatory compliance (HIPAA, FDA, ICH-GCP)
Standardized templates and validation tools
De-identification and privacy protection
Professional medical terminology (SNOMED-CT, LOINC)
AI-generated clinical timelines and diagrams

Core Capabilities

Case Reports: CARE-compliant case reports for journal submission with patient consent, de-identification
Diagnostic Reports: Radiology (structured reporting, BI-RADS, LI-RADS), pathology (CAP synoptic), laboratory results
Trial Reports: Serious adverse event (SAE) reports, clinical study reports (ICH-E3 structure), protocol deviations
Patient Documentation: SOAP notes, history & physical (H&P), discharge summaries, progress notes
Privacy: HIPAA Safe Harbor de-identification, 18 identifiers removal
Quality: Standardized medical terminology, audit trails, validation checks

When to Use

Writing case reports for journal submission (CARE guidelines)
Creating diagnostic reports (radiology, pathology, laboratory)
Documenting clinical trial data and adverse events
Preparing clinical study reports (CSR) for regulatory submission
Writing patient progress notes, SOAP notes, clinical summaries
Drafting discharge summaries, H&P documents, consultation notes
Ensuring HIPAA compliance and proper de-identification

Document Types

Journal Case Reports: Structured abstract, timeline, patient consent, CARE checklist
Radiology: Technique, findings, impression, structured reporting (Lung-RADS, BI-RADS)
Pathology: Gross/microscopic description, diagnosis, synoptic cancer reporting (CAP)
Laboratory: Results with reference ranges, critical value reporting, QC information
SAE Reports: Event description, causality assessment, regulatory timelines (7/15 days)
ICH-E3 CSR: Synopsis, ethics, study design, efficacy/safety evaluation, comprehensive appendices
SOAP Notes: Subjective, objective, assessment, plan for clinical encounters
H&P: Chief complaint, HPI, PMH, medications, ROS, physical exam, assessment/plan

Source: https://github.com/K-Dense-AI/claude-scientific-writer/tree/main/skills/clinical-reports License: MIT