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