Medical Chart Template

Medical Chart Template

This medical chart template is used to effectively record a patient’s complete medical history and clinical data, including the patient’s demographics, vital signs, diagnoses, past or scheduled surgeries, current or prescribed medications, treatment plans, allergies, laboratory results, and immunization records. Using this template with an AI medical scribe like Heidi will allow you to:

• Quickly and accurately capture all relevant patient data
• Facilitate collaboration between healthcare teams through the sharing of thoroughly completed medical charts
• Maintain records of sensitive patient information while complying with HIPAA, GDPR, APP, and other regulations

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What is a Medical Chart Template?

A medical chart template is a structured document used to systematically document a patient’s clinical data and medical history over time. Medical charts started with only symptoms, treatments, and outcomes 4,000 years ago.

This evolved through Dr. Plummer’s unified records and Dr. Lawrence Weed’s SOAP note and POMR to today’s Electronic Health Records (EHRs) and AI-powered software leading to a complete record of medications, vitals, and more.

In this article, we’ll discuss the benefits of using medical chart templates, the parts of modern patient charts, and simple ways to use said templates.

Benefits of Having a Good Medical Chart Template

With a good medical chart template, healthcare providers can keep track of patient symptoms and treatment logs and have systematic and accurate charts. EHRs and AI technology further minimize errors from illegible handwriting, improve documentation speed, reduce duplicated tests, and keep patients well-informed.

Continuing to use a well-structured medical chart template will allow professionals to save time, getting an accurate record that others can also utilize.

Medical Chart Template Example

‍Essential Parts of a Medical Chart Template

Whether you're practicing in a high-volume urgent care clinic or a smaller specialty practice, having a consistent structure for each medical chart makes it easier to quickly understand the patient's history, current status, and care plan.

Below are the most essential components that should be included in every medical chart template to promote clarity, compliance, and high-quality care delivery:

• Patient information – full name, date of birth, gender, hospital ID, admission date, room/ward, primary physician, emergency contact
• Admission details – reason for admission, admitting diagnosis, allergies, advance directives
• Vital signs – date, time, BP (mmHg), HR (bpm), RR (breaths/min), Temp (°C/°F), O2 Sat (%), Pain (0-10)
• Medical history – past medical conditions, surgical history, family medical history
• Current medications prior to admission – medication, dosage, frequency, prescribing doctor
• Lab and diagnostic tests – date, test ordered, results, notes
• Progress notes – patient history and current status, presentation during appointment, assessment and treatment discussions, plan and recommendations
• Treatment plan – medications prescribed, therapies ordered, dietary restrictions, activity level
• Nursing notes – date, time, nurse name, observations, and interventions
• Discharge summary – date, final diagnosis, procedures performed, discharge medications, follow-up appointments, patient education provided
• Physician and nurse signature

Depending on the clinician’s, hospital’s, or region’s specific requirements, a medical chart may also include the following:

• Consultation notes
• Second-opinion notes
• Operative procedure notes

These essential parts can streamline medical record-keeping accurately. Additional notes can also provide more context on why a patient is readmitted as well as other information that may prove useful. All these can be configured through Heidi to streamline the process.

Priority Physicians, a premier primary care and concierge medicine provider, reported that they managed to reduce their charting time by 70%. This translates to saving more than 100 hours on documentation.

Dr. Fraser said that she previously spent “2-2.5 hours writing notes for a full day of seeing patients,” and that she’s now down to around 40 minutes.” Utilizing Heidi for documentation can help medical professionals use medical chart templates and negate the issues of manually writing or encoding notes. Watch the video below to see Heidi in action:

Simple Ways to Write Medical Charts Faster

Medical charting has undergone a series of transformations, starting from carvings on tablets to handwritten notes on paper and punched cards. Eventually, typing notes on EHRs became the norm, but here are other tactics you can implement to further accelerate clinical documentation:

Use Standardized Template Formats

Standardizing your medical chart format allows you to use a consistent structure you can master through repetition. This can reduce the time spent consulting a chart on what information to get next and quicken note-taking compared to writing without a template.

Be Clear and Concise

You can continue writing clearly while keeping things short by abbreviating terms and using bullet points. This reduces the number of letters and words written and allows you to better track what the patient is saying or to simply save time when digitizing a chart.

Implement Team Documentation

Have non-physician team members assist you with your note-taking. This will allow you to focus on the patient while others handle filling out the chart either in real time or when digitizing it. Ensure that said team members do not make frequent errors.

Use an AI Medical Scribe

If you do not have a team member to assist you, then you can take advantage of AI medical scribes. Utilizing this tech improves the workflow of surgeons and residents by increasing the average number of patients seen per day. It stands to reason that a similar result will be present when filling out a chart.

Using Heidi Health’s AI medical scribe is one of the best ways to write medical charts faster without sacrificing accuracy.

Easily Fill Out Medical Chart Templates with Heidi

Our AI medical scribe simplifies filling out medical charts. You’ll only need to record the conversation after getting permission from your patient or provide information in the context section and let Heidi fill out the chart.

• Transcribe – Using your desktop computer, mobile device, or web browser, press “Start transcribing” to capture your conversation with the patient. You can also upload a transcription or encode patient information under the Context tab.
• Customize – Heidi will auto-populate a chart template using information from the recording and context notes. You can then edit the chart to add or remove information as necessary, especially when just starting out with Heidi.
• Transform – You can ask Heidi to use a specific medical chart template both before and after a chart is populated. When necessary, you can also ask Heidi to turn it into any other document, like a progress note or a discharge summary, etc. 

Heidi supports more than 1 million patient consults globally every week to streamline clinical documentation while maintaining accuracy. Our AI medical scribe also complies with leading data privacy standards such as HIPAA, GDPR, ISO 27001, and SOC 2 certifications, among others.

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Free Medical Chart Template Samples

Hospital Chart Template

A hospital chart template is a medical chart that focuses on a patient’s hospital stay. This is used by hospitals for inpatient care to record and organize medical history, treatments, progress notes, and other relevant details.

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 Patient Medical Chart Template

This medical chart template focuses on a patient’s lifetime medical history. Used for both inpatient and outpatient care, the details recorded in this template include the patient’s demographics, medical history, family medical history, immunization records, treatment history, and doctor’s notes and follow-up care.

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 Simple Medication Chart Template

Designed to track a patient’s medication schedule, this medication chart template helps ensure proper dosage and administration. This chart’s scope only includes the medication’s details and is used in hospitals, clinics, nursing homes, and other facilities.

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FAQs About Medical Chart Templates

What is the best format for a medical chart template?

The best medical chart format will be the one that suits your needs. Notably, this will typically comprise the standard patient information, medical history, chief complaint, findings, a treatment plan, and a SOAP note. An editable digital format is ideal since you can further tailor the template to include other information as necessary.

Are medical charts, records, and reports different from each other?

Yes, they are all different from each other because a medical chart is the systematic documentation of a patient’s information, a medical record is the comprehensive collection of information that a chart is typically a part of, and a medical report summarizes findings, observations, and other details on a patient’s medical care.

How can I write my own medical chart notes?

You can write your own notes by setting up a template to follow for note-taking or letting an AI scribe do the writing for you. You can create a template yourself using Heidi to tailor the chart according to your needs, depending on your department. You can review our guide for creating custom templates.