Clinical Report Writing
Safety Boundary
Use this skill for drafting and structuring medical documentation. Do not assert diagnosis, causality, guideline compliance, or regulatory status without current source verification and user-provided facts.
Workflow
- Classify report type: case report, diagnostic report, clinical trial/SAE/CSR document, SOAP note, H&P, discharge summary, or consultation note.
- Confirm privacy constraints and remove identifiers before analysis or drafting.
- Read the relevant checklist for report type, then verify any clinical guideline, CARE/CONSORT/STROBE/ICH statement, or disease fact against current sources.
- Draft with clear separation between user-provided data, interpretation, missing data, and literature-backed context.
- Keep required sections only; avoid copying long generic checklists into the output.
- Validate de-identification, consent language, source dates, and limits of interpretation.
References
- Read
references/source-notes.mdbefore citing guidelines, regulatory standards, or clinical facts. - Read
references/clinical-report-checklist.mdfor report-type routing and de-identification checks. - Read
references/legacy-full-skill.mdonly for detailed legacy templates, CARE checklist text, and LaTeX formatting patterns.
Validation
- All patient facts are either supplied by the user or explicitly marked missing.
- All current clinical claims are dated and sourced.
- The report includes review/sign-off language when used for clinical or regulatory contexts.