Examples of doctor note templates include a medical excuse form or a certificate of absence, according to TidyForms. Other doctor note templates can be used to document initial visits, acute complaints, chronic issues, operations and hospital stays, the University of North Carolina School of Medicine states.Continue Reading
One type of doctor note template documents the medical care received and certifies absence from school or work due to a doctor's appointment, reports TidyForms. Other doctor note templates may list the diagnosis and any clearance or restrictions placed upon the patient. Another example of a medical note template excuses a patient from federal jury duty due to certain medical conditions.
Doctor note templates should include the person's name and unit number as well as the visit date on each sheet, reports the University of North Carolina School of Medicine. The treating physician's name should also be clearly mentioned on the template. Many clinics utilize the SOAP template for outpatient clinic notes, which includes subjective, objective, assessment and plan sections. The subjective section reports the symptoms as related by the patient. The objective section includes results of the physical examination and test data collected since the person's previous visit. The assessment includes the physician's interpretation, and the plan includes future treatment.
Some clinics may use traditional headings for inpatient history and physical note templates such as history of present illness, past medical history, medications, family and social history and review of systems, the University of North Carolina School of Medicine explains. Guidelines for preparing doctor note templates as well as sample doctor notes are available on school's website. Detailed information on the required inclusions in different types of doctor note templates, such as history and physical examinations, clinic notes, discharge summaries and operative notes, are available from Georgia Regents University's PAWS.com site.Learn more about Software