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)
- MS Word
Doctor’s Note for Air Travel During Pregnancy
Medical Record Progress Note
Medical Death Note
- MS Word
Doctor’s Note for College Students
- MS Word
Medical Procedure Note
- MS Word
Medical Soap Note
Medical Sick Note Format
Doctors Note for Work Sample
- 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.