alterlab-clinical-reports
Clinical Report Writing
Overview
Document medical information with precision, accuracy, and regulatory compliance. This skill covers four report families: case reports for journal publication, diagnostic reports for clinical practice (radiology, pathology, lab), clinical trial reports for regulatory submission (SAE, CSR), and patient documentation for medical records (SOAP, H&P, discharge).
Clinical reports have to be accurate, complete, objective, and compliant with the applicable regulations (HIPAA, FDA, ICH-GCP), because they feed patient care, regulatory decisions, and the published record. Use only clinical data the user provides — never invent findings, lab values, dates, or citations to fill a template — and mark anything unknown as a placeholder for the clinician to complete. Drafts are for review and sign-off by the responsible clinician or investigator.