After Visit Summary Template with Examples

After Visit Summary Template

This after visit summary template can easily help you produce complete yet concise summaries of your patient's visit, ensuring that they have a good picture of their diagnosis, treatment plan, and next steps. With Heidi, you can leverage the benefits of AI to automatically generate doctor visit summaries that:

• Include essential visit details such as the patient’s name, date of birth, reason for the visit, diagnoses, prescribed medications, and recommended treatments.
• Summarize key medical discussions by outlining test results, procedures performed, and any adjustments to the patient’s treatment plan, helping them stay informed about their health status.
• Provide clear follow-up instructions such as upcoming appointments, self-management tasks, and lifestyle recommendations that is worded in a way that is easily comprehensible by your patients and their support system.

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What is an After Visit Summary Template?

An after visit summary (AVS) template,  is a formatted printed or electronic document used to capture a concise summary of a singular patient’s visit to a physician. Also known as patient visit summary template, it covers critical patient-specific information such as diagnoses, treatments, medications, upcoming appointments, and personalized self-care instructions meant to help support patient education.

In this piece, we’ll cover the common challenges of today’s after visit summaries, advantages of using an after visit summary template, how to write an after visit summary and its key components. Lastly, we’ll share with you pre-designed AVS templates which you can customize to fit your practice.

After Visit Summary Pain Points of Doctors and Patients

When it comes to after visit summaries, there are two primary stakeholders: the healthcare providers (doctor, GP, clinicians) who write the summary and the patients who rely on its contents.

Both stakeholders alike have encountered several challenges with regard to the use of after visit summaries. Below are some of the most common pain points that they have raised.

On the side of healthcare providers: 

Time Constraints & Documentation Workload

Physicians often deal with back-to-back patient visits and with the limited time per visit, writing a complete after visit summary each time already adds to the heavy documentation workload they have.

Doctors admittedly often fall into the pitfall of rushing through the after visit summary or extend beyond clinic hours, ultimately leading to burnout. 

Inaccurate Summaries

Rushed documentation increased the possibility of having inaccurate or vague summaries, reducing the very essence of the after visit summary. Pre-generated templates are available, but some clinicians often find that they don’t always capture the specifics of the visit, making the summary feel generic. 

Delayed Summary Completion & Follow-Up Issues

Busy schedules often delay the completion of after visit summaries , meaning patients don’t receive their summaries before they leave. This can create gaps in care, especially if important follow-up details, such as referrals or test results, are not clearly outlined. 

Lack of Patient Engagement with After Visit Summaries

One of the biggest reported concerns of physicians is that many patients do not fully understand key details of the after visit summary, especially due to medical jargon or complex language.

This typically leads to patients ignoring critical instructions, which then causes frustrations on the doctor’s part due to poor follow-through on care plans.

Dr. Chris Bojrab, president of the Indiana Health Group (IHG), shared how Heidi, the AI medical scribe for all clinicians, significantly helped address that concern. "Before, I had to choose between having a crappy note or sacrificing the face-to-face experience with patients," he explains. "I'd either be madly typing to capture everything or trying to stay present while knowing my documentation would suffer."

"It’s (Heidi) improved our clinician-patient experience significantly," he continues. "It allows me to build a better note but at the same time actually talk to my patient more conversationally, be more present in the moment and still wind up with a good note."

On the side of patients: 

Critical Gaps in After Visit Summary Explanations

Some patients have noted that their after visit summary lacked comprehensive explanations of diagnoses, test results, or treatment rationales, making it hard for them to recall what was discussed.

In a sample study, 16% of patients received non-meaningful AVS, highlighting a common issue of after visit summaries failing to provide actionable information.

Lack of Patient Consultation in Documentation

Patients often find that decisions about medication changes or treatment plans are documented in the after visit summary without having been thoroughly discussed during the visit. This lack of consultation can result in frustration, distrust, and non-adherence to medical recommendations.

Delayed Access to Summaries

As noted earlier, delays in handing over the after visit summary to patients are quite common, preventing them from following post-visit instructions in a timely manner. This effect can be particularly problematic when patients need to start a new medication, schedule follow-ups, or seek additional care based on their visit.

Advantages of Using Customizable After Visit Summary Template

We recognize how essential AVS is for patient care, but the inefficiencies of today that comes with the use of after visit summary templates often result to stress and frustration for both doctors and patients.

With a more flexible solution in the form of customizable after visit summary templates, physicians can significantly save time and improve accuracy, helping patients understand their conditions and care requirements better and have better trust in their doctors.

Here’s exactly how customizable after visit summary templates can help address current challenges:

Streamlining Documentation Without Sacrificing Quality

Configurable patient visit summary templates can help streamline the process by allowing physicians to quickly modify pre-formatted sections instead of starting from scratch.

Whether updating medication changes, summarizing a diagnosis, or outlining follow-up steps, the templates help save valuable time, ensuring that no critical details are overlooked and the next instructions are documented before the patient leaves, preventing gaps in follow-up care.

Enhancing Accuracy and Avoiding Generic Summaries

Every medical practice requires a certain level of personalization to account for the unique conditions and needs of its patients, and fixed after visit summary templates can feel too generic, often failing to allow doctors to capture those case-specific details.

With customizability, physicians can tailor fit their ways of questioning according to the needs of their patients, ensuring that diagnoses, treatments, and follow-up plans are relevant and accurately documented.

Heidi, an AI-powered medical scribe, can help ensure that after visit summaries are not only personalized, but also compliant with regulatory standards,  such as the Health Insurance Portability and Accountability Act (HIPAA) in the U.S. and the General Data Protection Regulation (GDPR) in Europe.

Heidi's AI-driven solutions can help clinicians generate after visit summaries that are tailored to individual patient needs while maintaining compliance with the relevant regulations in your respective regions, ensuring both high-quality patient care and legal adherence. 

Increasing Patient Engagement and Understanding

After visit summary templates, especially when boosted with AI language processing,   enable patient-friendly language, allowing healthcare providers to simplify explanations and structure information for better readability and adherence for patients.

Overcoming EHR Limitations and Improving Workflow

EHR systems often come with rigid, non-customizable after visit summary formats that limit how thoroughly clinicians can communicate with their patients. Customizable templates — like those available at heidihealth.com/templates — give providers the flexibility to maintain consistency, personalize care, and adapt summaries to their workflow despite EHR limitations.

After Visit Summary Template Example

Key Components of an After Visit Summary

Crafting an effective after visit summary template requires careful structuring to ensure that it promotes a smoother workflow for you and for patients to find the information presented in it useful rather than overwhelming.

With this, it’s important to know the core components to be included in an after visit summary and the best practices for writing after visit summaries. 

The essential components of an after visit summary include:

Visit Details

• Includes the date, time, and purpose of the appointment for easy reference.
• Helps patients track their medical history and provides clarity on why the visit occurred.
• If applicable, a summary of the patient's chief complaint and concerns discussed should be included.

Physician Information

• Lists the name and contact details of the attending physician
• Ensures the patient knows whom to contact for further questions or follow-up.
• Can also include the provider’s credentials and specialty for context.

Diagnosis and Health Issues

• A brief summary of any diagnosed conditions or discussed health concerns.
• If multiple conditions are covered, a prioritized list can improve clarity.
• Patient-friendly language should be used to ensure understanding, and overly technical medical terms should be avoided unless necessary.

Medications

• A clear list of prescribed medications, including the name of the medication (generic and brand if applicable), dosage and frequency, administration instructions (e.g., "take with food," "avoid alcohol"), possible side effects, and what to do if they occur.
• Any changes to existing medications (adjustments in dosage, discontinuations, or new prescriptions) should be bolded or highlighted to ensure visibility.
• If applicable, notes on over-the-counter (OTC) medications, vitamins, or supplements relevant to the patient's condition.

Treatment and Procedures

• Details of any treatments provided or procedures performed during the visit.

Test Results and Lab Work

• A summary of test results (if available) with a brief explanation of their significance.
• If results are pending, the expected timeline and instructions on how to retrieve them should be included.
• If additional tests are required, a note on when and where to get them done is helpful.

Follow-Up Instructions

• Specifies the next appointment date and time; required tests, scans, or additional procedures; and any referral appointments that have been scheduled or need to be arranged
• Patients should understand the importance of follow-ups and what symptoms or changes in condition should prompt an earlier visit.

Referrals

• Details of any specialist referrals or additional healthcare providers involved in follow-up care.
• Should include the referred provider’s name, specialty, location, and contact details.
• If prior authorization or insurance approval is needed, this should be noted

Contact Information

• Office phone numbers and email contacts for any follow-up questions.
• Information on emergency contacts (e.g., when to go to urgent care or call the provider).
• If applicable, a portal login link for patients to access their medical records and secure messages with providers.

Patient Responsibilities

Clear and actionable instructions on:

• Medication adherence (reminders on when and how to take prescribed medications)
• Self-management techniques (e.g., blood sugar monitoring)
• Signs and symptoms to monitor (and when to seek medical help)
• General health education and advice on managing diagnosed conditions, lifestyle modifications (e.g., diet, exercise, stress management), and preventive measures (e.g., vaccinations, screenings, self-monitoring techniques)
• Should be personalized when possible to enhance patient engagement.
• Can include links to trusted resources for further reading (e.g., government health websites, hospital-provided materials).
• Should be written in a way that is easy to understand and follow.

Best Practices for Issuing After Visit Summaries

Below are some of the best practices to improve the usefulness of an after visit summary:

1. Define a Clear Agenda 

Before writing the after visit summary, establish a shared understanding between the patient and provider. Ask yourself, “ What does the patient want to learn?” or “What specific items do I need to discuss?”. A clear agenda ensures that the summary reflects the most relevant and useful information for the patient.

2. Designate Times to Collect Key Information

Establish a routine for asking about medications, symptoms, and treatment concerns at different points in the visit. This approach helps avoid last-minute scrambling to capture critical information.

3. Use Patient-Friendly Language

Avoid overly technical terms or medical jargon that patients may struggle to understand. Always try to provide concise explanations for diagnoses, test results, and especially the next steps when they get back home. 

4. Develop a Framework for Individualized Comments

You can try using a structured framework like:

What do you have? (Diagnosis or issue)

What does that mean? (Brief explanation)

What should you do about it? (Actionable steps for the patient)

This method ensures that every after visit summary remains informative and patient-specific while being efficient for providers.

5. Ensure the Summary Is Delivered in a Timely Manner

The goal is for patients to receive their summary immediately after the visit or within a reasonable timeframe. With an after visit summary template that is customized to fit your practice, you can achieve this goal more consistently. 

Writing after visit summaries can be time-consuming and prone to errors, and imagine it more when you’re used to manually charting them.

With Heidi, an AI-powered medical scribe, you can design after visit summary templates for the most common conditions of patients in your clinic and ensure that they’re fully customizable to meet each of their specific needs.

Save Time and Produce Patient-Friendly After Visit Summaries with Heidi 

Here’s how Heidi can fully transform your after visit summary charting process in three simple steps:

• Transcribe – During the consultation, Heidi listens and captures key details in real-time, ensuring that all essential information—diagnoses, medications, treatment plans, and follow-up instructions—is documented accurately. This reduces the risk of errors or missing information.
• Transform – Heidi automatically organizes the transcribed data into a format that is easily comprehensible for patients and other healthcare providers that may look into the after visit summary for billing, referral, or other purposes. 
• Customize – You can adjust the fields in your after visit summary template as you go as by adding specific instructions, personalizing recommendations, or emphasizing key patient responsibilities. 

Once finalized, your after visit summary can be instantly shared with patients through digital portals, eliminating delays and helping them stay on track with their care. Heidi also flags important reminders, such as upcoming lab tests or medication changes, to ensure better patient follow-through.

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Customizable After Visit Summary Templates

Doctor Visit Summary Template

The Doctor Visit Summary Template helps General Practitioners provide patients with a clear, concise record of their consultation. It outlines key discussions, diagnoses, and next steps, ensuring better patient understanding and adherence to treatment plans.

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New Patient Visit Summary Template

The New Patient Visit Summary Template helps healthcare professionals efficiently summarize a new patient’s medical history and past visits. It provides a concise yet comprehensive overview of presenting conditions, treatments, and progress, ensuring continuity of care and informed decision-making.

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Patient After Visit Summary Template 

The Patient After Visit Summary Template helps psychiatric nurses provide a clear summary of a patient’s visit and care plan, including treatment, medications, follow-ups, and referrals. Designed for psychiatric settings, it ensures clear communication and supports patient understanding and compliance.

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FAQs about After Visit Summary Templates

Why is it important to go over the after-visit summary with the patient?

Reviewing the after visit summary ensures that patients understand their diagnosis, treatment plan, and follow-up instructions, reducing the risk of miscommunication. It also provides an opportunity for patients to ask questions and clarify any concerns, leading to better adherence to medical advice.

What is a physician's visit summary and encounter summary of a patient?

A physician's visit summary, also known as an after-visit summary, is a document given to patients after their appointment, outlining key details such as diagnosis, treatment, medications, and follow-up steps. An encounter summary is a broader term used in medical records to document all aspects of a patient’s visit, including history, physical examination, and provider notes, primarily for internal use.

How can healthcare providers ensure the accuracy of patient visit summaries?

Healthcare providers can improve accuracy by using structured templates and verifying key details before finalizing the summary to minimize manual errors. Additionally, reviewing the summary with the patient and encouraging questions can help confirm that all information is correct and understood.