Chart Note Template
Keep your notes organized, well-formatted and readable with this chart note template.
Fact Checked by Nate Lacson.
What is a Chart Note Template?
Chart notes are an important tool for facilitating communication between members of a patient's care team about any updates on the patient's condition. Our chart notes template is designed to make it easy to keep track of entries and maintain shareability and accountability within your patient's team. Chart notes act as a chronological journal of relevant updates for your patient, and using a pre-formatted, laid-out template like Carepatron's chart notes template is a great way to keep you organized.
Printable Chart Note Template
Check out our downloadable chart note template to keep your notes HIPAA compliant.
Printable Chart Note Template
Check out our downloadable chart note template to keep your notes HIPAA compliant.
How to use this Template For Chart Notes
This template makes taking chart notes a breeze. With column titles pre-filled in for you and clear spaces for you to add in your entry to your chart notes, you can save time formatting your notes and get back to looking after your patients. Follow these easy steps to start taking chart notes with Carepatron's handy template.
1. Download the PDF
First, you need to download the PDF from the provided link to edit it locally or continue to print it out and fill it in by hand.
2. Fill in the patient information
This only needs to be done once per sheet and includes the patient's name, date of birth, optional identifier, and room number.
3. Enter the date and time, and focus
The date and time column makes it easy to remember to date your entries into a patient's chart notes. Make sure you include this for each separate entry. Timing can be crucial in chart notes as well, as often, a patient will have many entries on the same day. The focus column is for a summary of what particular issue your note refers to.
4. Write your progress note
The progress note column is for your chart note. There are many acronyms for taking progress notes, such as SOAP or F-DAR, and our template is simple enough to allow you to take notes in your preferred style. Alternatively, you can find SOAP note templates in our template library.
5. Sign the note, and store it securely
Once you've finished writing your progress note, sign or initial it so others know who wrote it when they come to read it. Finally, your patient's chart notes need to be stored securely to prevent a violation of HIPAA and in a place that can be easily accessed by other healthcare workers who need to add to the chart notes.
Chart Note example (sample)
We have provided a sample below to help you understand what sort of information can go in these Chart notes and what the template might look like when filled out.
Check out and download the Chart note example here:
Who can use this Printable Chart Note Template?
Ward nurses commonly use chart templates but might be used by many different members of your patient's care team. These might be:
- Nurses
- Resident doctors
- Overnight shift staff
- Allied health workers
- Care workers
- Resident or trainee healthcare workers.
Regardless of who is writing an entry into the chart notes, this clinical template standardizes everyone's entry and keeps the chart notes simple and readable.
Why is this Template useful for nurses?
Don't rely on your memory
Our template takes the stress out of remembering to date and sign your chart notes. Additionally, with one space for patient information in the header, once this is filled in appropriately, you won't have to worry about it again! Nurses are often incredibly busy and pressed for time during their shifts, so anything that takes a bit of the mental load off is a win!
Encourage collaboration
Having a template that clearly shows how to add an entry to the patient's progress notes encourages collaboration across your patient's team, as writing a short update in a patient's progress notes is a lot quicker than sending out a communication to everyone who might need to know in the future.
Provide evidence of your professional development
Nurses may be required to provide evidence of their activities to get signed off as part of their training if they are still students, or professional development if they are already qualified. Our chart notes template is a great way to provide evidence to your tertiary institution or professional body of your abilities as a nurse.
Why use Carepatron for Chart Notes?
Your chart notes are important medical records that may record information for many clinicians, such as nurses, allied medical professionals, doctors and residents, therapists, or other healthcare workers. As such, having a designated, secure place to store these notes and a clear process of contributing is important to prevent losing information, accidental overwriting, or a security breach.
Carepatron offers a HIPAA-compliant method to store your completed chart note templates. As well as being secure, Carepatron is easily accessible for all members of your patient's care team.
You can find this template and many others and use it right within Carepatron. Keeping your notes digital is more secure than paper, and many people prefer typing to handwriting!
Carepatron also offers smart speech-to-text dictation software, compatible with all our clinical templates, and a suite of useful practice management features such as appointment scheduling, billing management, and video call functionality.
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Commonly asked questions
The main purpose of writing an entry into a patient’s chart notes is to create a record of important updates, information, or results relevant to your patient. This written documentation is required under HIPAA for health practitioners as part of your patient’s medical record, but it is also an important tool for communicating between staff members.
Chart notes are succinct updates on your patient given in chronological order and often created by various members of a multidisciplinary care team. As such, it is important your chart notes are legible for others, have your initials or signature so others know who wrote the entry, and are succinct enough to cover just the key information or update. With this in mind, our chart note template has separate columns for the date and time, and your signature, to ensure you don’t forget these important details.
Since different staff members might be using the same chart notes for one patient, it’s important to put the date and time of your chart note and fill in the template chronologically from top to bottom. Additionally, if you are keeping this resource digital- it is important to make sure all members of the patient’s care team are aware of the risks of overwriting each other when using the same document. It’s a good idea to ensure a document cannot be opened in multiple places at once when it is being shared by multiple people.
