General Medical Documentation Templates

Download Compete Set of Note Templates

If you have NaturallySpeaking Professional, Medical or Legal, you can download this command and import it directly into your user profile via the command browser.

Contained within this command set is a series of structural note templates potentially useful to a medical practitioner. These are all simple text commands. Some still have reference to the author's institution (DHMC) so you will want to look through these carefully and remove such references. All of these note templates have "navigation fields" to allow for quick movement to specific places within each note. If you have not yet downloaded commands for field navigation, you can do so at the Field Navigation Command page. A few of the notes contain language in which a generic "ProviderName" is present and in which you can use the "Text Replacement Command" to quickly insert alternative text in the place of this generic providername. Visit the Text Replacement Command page to download this command.

The following is a list of note templates contained within this single command set:

Brief Procedure Template
CCU Fellow Admit Template
Discharge Summary Template
Fellow Admit Template
Fellow Backup Template
Fellow Consult Template
Inpatient Admit Template
Inpatient Consult Template

Linked Note Header
Mid Level Back up Template
Mid Level Admit Template
New Patient Evaluation
New Patient Template
Outpatient Consult Template
Progress Note Template
Soap Template

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Learn about the Note Templates

Detailed on this page are a variety of medical note templates used frequently in the author's cardiology practice. Although some may be useful to you in their current format, many or most should probably be changed slightly to suit your own practice and documentation preferences. A few of these templates still contain the name of the author's institution (DHMC), which you'll want to remove and replace with your own hospital or practice name. These are intended only to give you a "jump start".

If you are working with an electronic health record (EHR) which will allow pre-population of a note with patient demographics, vital signs, and other information, I would recommend that you build note templates of this nature within your EHR, add navigation fields, and work within your EHR rather than using the stand-alone templates described here.

A Note on NavigationFields: Numerals between brackets ([01],[02],[03], etc.) represent field "navigation fields" and allow immediate navigation to and selection of the entire field block, simply by saying "field one", "field two", etc. These are used primarily in note templates to allow quick navigation to locations specified by the field identifier. You can create your own filed within note templates simply by creating the appropriate bracketed numbers. Alternatively field can be created by voice wherever you curser is active by saying "insert field one", "insert field two", etc. To learn more about navigation commands, please visit my Navigation Field Command page.

Several of these notes are intended to be linked to a note already completed by a resident, fellow or mid-level provider and may contain the term "ProviderName" or "MidLevelName". It is intended that these note be used with my Text Replacement Command, described elsewhere which will substitute the name of the actual provider for the generic term.

SOAP Template

SUBJECTIVE: [01]

OBJECTIVE: [02]

ASSESSMENT: [03]

PLAN:

1. [04]

New Patient Template/New Patient Evaluation:

NEW PATIENT HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: [01]

HISTORY OF PRESENT ILLNESS: [02]

PAST MEDICAL HISTORY:

1. [03]

MEDICATIONS: [04]

ALLERGIES: [05]

SOCIAL HISTORY: [06]

FAMILY HISTORY: [07]

REVIEW OF SYSTEMS: [08]

PHYSICAL EXAMINATION: [09]

ADDITIONAL DATA: [10]

ASSESSMENT: [11]

PLAN:

1. [12]

Outpatient Consult Template:

OUTPATIENT CARDIOLOGY CONSULTATION - [01]

REQUESTING PHYSICIAN: [02]

REASON FOR CONSULT: [03]

HISTORY OF PRESENT ILLNESS: [04]

PAST MEDICAL HISTORY:

1. [05]

MEDICATIONS: [06]

ALLERGIES: [07]

SOCIAL HISTORY: [08]

FAMILY HISTORY: [09]

REVIEW OF SYSTEMS: [10]

PHYSICAL EXAMINATION: [11]

ADDITIONAL DATA: [12]

ASSESSMENT: [13]

PLAN:

1. [14]

Inpatient Consult Template:

INPATIENT CARDIOLOGY CONSULTATION - [01]

REQUESTING PHYSICIAN: [02]

REASON FOR CONSULT: [03]

HISTORY OF PRESENT ILLNESS: [04]

PAST MEDICAL HISTORY:

1. [05]

MEDICATIONS: [06]

ALLERGIES: [07]

SOCIAL HISTORY: [08]

FAMILY HISTORY: [09]

REVIEW OF SYSTEMS: [10]

PHYSICAL EXAMINATION: [11]

ADDITIONAL DATA: [12]

ASSESSMENT: [13]

PLAN:

1. [14]

Inpatient Admit Template:

CARDIOLOGY INPATIENT ADMISSION HISTORY AND PHYSICAL EXAMINATION:

CHIEF COMPLAINT: [01]

HISTORY OF PRESENT ILLNESS: [02]

PAST MEDICAL HISTORY:

1. [03]

MEDICATIONS: [04]

ALLERGIES: [05]

SOCIAL HISTORY: [06]

FAMILY HISTORY: [07]

REVIEW OF SYSTEMS: [08]

PHYSICAL EXAMINATION: [09]

ADDITIONAL DATA: [10]

ASSESSMENT: [11]

PLAN:

1. [12]

Progress Note Template:

CARDIOLOGY INPATIENT PROGRESS NOTE

CLINICAL PROBLEMS:

1. [01]

24 HOUR EVENTS: [02]

EXAMINATION: [03]

PERTINENT DATA:

[04]

ASSESSMENT: [05]

PLAN:

1. [06]

Discharge Summary Template:

DISCHARGE DIAGNOSES:

1. [01]

PROCEDURES:

1. [02]

HISTORY OF PRESENTATION: [03]

HOSPITAL COURSE: [04]

DISCHARGE MEDICATIONS: [05]

FOLLOW-UP: [06]

Brief Procedure Template:

BRIEF CARDIAC PROCEDURE REPORT:

Proposed Procedures:

1. [01]

Actual Procedures:

1. [02]

Post Operative Diagnosis:

1. [03]

Surgeons:

1. [04]

Anesthesia: [05]

Estimated Blood Loss: [06]

Drains and Tubes: [07]

Findings, Complications, and Other Information: [08]

Midlevel Admit Template: (An admission note linked to that of a mid-level provider)

CARDIOLOGY ADMISSION NOTE

This patient has been admitted to the Cardiology Service under my care for the management of [01]. The patient has been seen in conjunction with a mid-level provider, ProviderName. I have independently interviewed and examined the patient and agree with the documentation provided by ProviderName.

Clinical History: In brief, [02]

Pertinent Physical Findings:

[03]

Pertinent Data: [04]

Assessment: [05]

Plan:

1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family

2. Options for management were reviewed

3. [06]

[Note regarding this template: this is a generic template with the fellow's name replaced with text "FellowName". The actual fellow name is inserted after the template is formed by using the "Replace <fellowname>", "Replace <MidLevelName>" or "Generic Replace" templates described below.]

Mid level Backup Template: (A daily progress note for inpatients linked to a midlevel provider's note)

CARDIOLOGY DAILY PROGRESS NOTE

The patient was seen today with the mid-level provider, ProviderName. I have independently interviewed and examined the patient and reviewed pertinent historical, laboratory, and other data. Please refer to ProviderName's note for details of this patient's presentation, findings, and recommendations. I have reviewed ProviderName's note and concur fully with documented findings.

In brief, [01]

Physical Examination: [02]

Pertinent Data:

Labs: [03]

Assessment: [04]

Plans:

1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family

2. Options for management were reviewed

3. [05]

Fellow Consult Template:

CARDIOLOGY CONSULTATION

Requesting Physician: [01]

Clinical History: The Cardiology Service was asked to evaluate this patient regarding: [02].

The patient was seen in conjunction with Dr. ProviderName. I have independently interviewed and examined the patient and reviewed pertinent historical, laboratory, and other data. Please refer to Dr. ProviderName's note for details of this patient's presentation, findings, and recommendations. I have reviewed Dr. ProviderName's note and concur fully with documented findings.

In brief, [03]

Physical Examination:

[04]

Pertinent Data: [05]

Assessment: [06]

Recommendations:

1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family

2. Options for management were reviewed

3. [07]

Thank you for allowing me to assist in the care of this patient. For questions or to discuss the case further, please contact me at my Lebanon DHMC office (603-650-7840) or through pager 2528.

Fellow Admit Template

CARDIOLOGY ADMISSION NOTE

Clinical History: This patient was admitted to DHMC with the chief complaint: [01].

In brief, [02]

Physical Examination:

[03]

Pertinent Data: [04]

Assessment: [05]

Recommendations:

1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family

2. Options for management were reviewed

3. [06]

Fellow Backup Template:

CARDIOLOGY OUTPATIENT NOTE

Chief Complaint: [01]

Clinical History: This patient was seen in conjunction with Dr. ProviderName. I have independently interviewed and examined the patient and reviewed pertinent historical, laboratory, and other data. Please refer to Dr. ProviderName's note for details of this patient's presentation, findings, and recommendations. I have reviewed Dr. ProviderName's note and concur fully with documented findings.

In brief, [02]

Physical Examination: [03]

Pertinent Data: [04]

Assessment: [05]

Recommendations:

1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family

2. Options for management were reviewed

3. [06]

CCU Fellow Admit Template:

CARDIOLOGY CCU ADMISSION NOTE

Clinical History: This patient was admitted to the DHMC Coronary Care Unit with the chief complaint of: [01].

In brief, [02]

Physical Examination:

[03]

Pertinent Data:

12 Lead ECG: [04]

Labs: [05]

Other data: [06]

Assessment: [07]

Diagnoses: [08]

Recommendations:

1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family

2. Options for management were reviewed

3. [09]

Linked Note Header:

CARDIOLOGY STAFF INPATIENT NOTE

This patient was interviewed and examined with Dr. ProviderName during rounds today. Please refer to clinical documentation of the history, physical examinations, data summary, and both assessment and plan as documented by Dr. ProviderName, with which I agree.

Clinical History: Briefly, [01]

Physical Examination: [02]

Data: [03]

Assessment: [04]

Plan:

1. [05]