A patient note is an essential record that is required in every medical setting such as clinics or hospitals. It is part of a medical document where medical professionals record vital information such as the clinical standing of a certain patient during the time of confinement or during an outpatient assistance.
A patient note can be written in a different format and this will depend on every medical circumstance and on the medical professional who handles it. When making a patient note, you need to make sure that the details you’ll include are all factual and correct. In case you want to see what a perfect patient note looks like, we have patient note templates that you can refer and also download.
How to Make an Effective Patient Note
It is necessary to have accurate details when writing up a patient note. Follow these steps for a more precise and purposeful patient note.
- Make it straight to the point. Document all required and relevant details. However, keep in mind that you need to avoid any irrelevant information.
- Include details that are appropriate and applicable. Not including important information that will provide explanation toward the treatment decision is highly discouraged.
- Always be cautious when describing the treatment of a patient. This section should provide a clear and sensible data.
- Keep in mind that other medical professionals will also view your patient note. This is for you to be meticulous when writing your patient note. Information should be factual and will support any questions from other medical professionals.
- Make your handwriting legible and clear. Writing a coherent patient note is important since this will serve as a defense against any form of legal action. This also applies when writing a medical note, and for an accurate note making, you can use our medical note template.
- Always observe a patient’s privacy, this should be a top priority. You don’t need to include or mention someone who is not needed or relevant to the patient’s note.
Additionally, we also have thank-you notes in case you need them.
Sample Patient Note
Example of Patient Note
Diabetes Care Patient Note
Samples of Our Patient Note Templates
For a great and effective medical communication, having an excellent patient note is vital. With this being said, a patient note should contain truthful and complete records. Now, if you want a more convenient and easier way of making a patient note, we offer an array of patient note templates for you to choose from. We also have doctors note template samples for other options.
- Patient Evaluation Template – This is a type of template that focuses on evaluation purposes. This contains information such as patient’s name, the patient’s progress, medications or procedures taken, and other relevant information.
- Patient Death Note Template – This is made when a certain patient dies during confinement or hospitalization. It contains specific information such as patient’s complete name, the cause of death, and time of death.
- SOAP Note Template – This is an acronym for subjective, objective, assessment, and plan. This is an ideal note to use when it comes to documentation provided by health care providers.
- Diabetes Care Patient Note Template – This is a special note that is intended for a patient with diabetes. It contains needed details such as physical exam assessment, medications, patient’s progress, and so on.