Home   /   Sample Notes   /   

Medical Note Template

A lot goes into a visit to the hospital. Your doctor needs to keep track of your symptoms, testing, diagnosis, treatment, and prognosis. All this information can be hard to make sense of if presented in different documents. Fortunately, a doctor can record patient history in a medical note.

A medical note, also called a doctor’s certificate, is a legal document presented to a patient by their physician. It details the patient’s illness and keeps a record of their health situation.

What’s more, it can serve as a legal document when making insurance claims, filing taxes, or requesting a leave of absence from work or school.

In this article, we look at how to fill out a medical note template accurately.

What Should Be Included in a Medical Note Template

Typically, a medical note template should contain 4 main components. These components, which are usually referred to a SOAP include:

  • Subjective Component – An account of the patient’s symptoms recorded in their own words.
  • Objective Component – The findings of the doctor following diagnostic tests.
  • Assessment – A diagnosis of the patient’s condition.
  • Plan – All treatment methods the doctor will use to assist the patient

Tips for Writing a Medical Note

A medical note is a very critical formal document. Use the following tips to help you draft your note accurately:

  • Include the time and date of every entry
  • Avoid copy-pasting previous medical notes
  • Minimize or avoid the use of abbreviations to promote understanding
  • Include your name, title, and signature in the note
  • Draw a line through any errors and sign beside them

Medical Note Format

{Date}

{Hospital/Clinic/ Health Center/Doctor Name}

{Hospital/Clinic/Health Center/Doctor Address}

{City, State, Zip Code}

Re: Patient Name/ Case File Number

Patient Information

Name: {Patient’s Name}

Age: {Patient’s Age}

Gender: {Patient’s Gender}

Date of Birth: {Patient’s DOB}

{Dear sir/madam} or {To whom it may concern},

The above patient arrived at {hospital/health care center name} on {date}. {He/She} was showing the following symptoms {describe symptoms}. After conducting {name prescribed tests}, {he/she} was diagnosed with {name of condition}.

The patient has been receiving treatment for {amount of time} and has shown {mention progress}. I, therefore, recommend that {he/she} take time off work to rest for {amount of time}.

Sincerely,

{Doctor’s Signature}

{Doctor’s Name}

Sample Medical Note

18 August 2020

Annex Hospital

456 Second Street

Houston, TX 45678

Re: George Smith File Number AH/GS/4/20

Name: George Smith

Age: 40

Gender: Male

Date of Birth: 4 May 1980

Dear sir/madam,

Mr. Smith was admitted to Annex Hospital on 11 August 2020 with severe chest pains and heart palpitations. After an MRI test and CT scan, he was diagnosed with acute bronchitis. He has been receiving treatment at the hospital since.

I plan to discharge Mr. Smith on 19 August 2020 with recommendations to observe a 7-day bed rest period. Therefore, I recommend that he be excused from work until then.

Sincerely,

Faith Hadassah

Different Type of Medical Note Templates

A doctor can handwrite a medical note. However, for better accuracy, it is advisable to use a standard medical note template. Here are a few examples:

Medical Note (Word Template)

Details
File Format
  • MS Word

Doctor’s Note for Air Travel During Pregnancy

koreanair.com
Details
File Format
  • PDF

Medical Record Progress Note

This is an ongoing record of a patient’s progress in terms of illness and treatment. The frequency with which the note is written depends on the severity of the patient’s condition.
dtic.mil
Details
File Format
  • PDF

Medical Death Note

A death note is a document detailing the information surrounding the death of an individual. It states the cause and time of death.
berkshirehealthsystem.org
Details
File Format
  • MS Word

Doctor’s Note for College Students

Details
File Format
  • MS Word

Medical Procedure Note

This is a document added to a patient’s chart after a certain medical procedure had been completed. It describes the type, performance date, and outcome of the process executed on a patient.
berkshirehealthsystem.org
Details
File Format
  • MS Word

Medical Soap Note

A soap note is a medical record written by a physician to document a patient’s initial visit, follow up care, and progress. It can help reduce confusion where different healthcare professionals are seeing one patient.
oucom.ohio.edu
Details
File Format
  • PDF

Medical Sick Note Format

Medical Sick Note. A sick note is a formal statement written by a doctor to attest that a person is unwell and unable to work. It can be presented to an employer when requesting for a leave of absence.
doctorsns.com
Details
File Format
  • PDF

Doctors Note for Work Sample

Medical Doctor’s Note. A medical doctor’s note is written by a physician to state that they had an appointment with a patient on a specific date. It can also detail the findings of that appointment, such as a diagnosis.
Details
File Format
  • MS Word

Conclusion

A medical note can summarize your treatment and help you convince your employer that you deserve a leave. As such, it should be drafted with the utmost care. A well-written note should be accurate and informational, but easy to understand. You can achieve this by using a medical note template.

Your Header Sidebar area is currently empty. Hurry up and add some widgets.