What Is A Medical Record Summary Template
A is a patient’s full collection of progress notes, test results, encounters, appointment notes, and all other documentation relating to the patient’s medical history. For patients with long-term or multiple health conditions, or with treatments spanning across multiple providers, this medical record can quickly become very long and tricky to decipher. There are several situations where you may need to summarize a patient’s medical record, including when their medical record has become disorganized or difficult to interpret, but perhaps the most common is in a legal situation where a patient’s medical record must be accurately summarized in order to settle a medico-legal case, and that’s where our comes in!
This template serves as a skeleton for summarizing a patient’s medical record and includes important details, space for dates and times, and handy page numbering. Using this template will create an organized and concise chronology of your patient’s medical record, and serve as invaluable evidence if ever you find yourself needing to provide an accurate, chronological account of a patient’s medical history.
How To Use This Free Medical Record Summary Template
Our free Medical Record Summary Template is straightforward to start using, but to make sure you understand how to complete each section, just follow these simple steps.
Step One. Download the Medical Record Summary Template
The first step is to download the Medical Record Summary Template. You can download the free PDF version of this template using the link on this page, or you can find this template, and many others, from within Carepatron’s community template library. Don’t worry about fitting in all the information on the first page, you can make as many copies of the second page of the PDF as you need for your Medical Record Summary and number them once you are finished.
Step Two. Fill in the Patient Information
Once you have a copy of the template, fill in the Patient Information and Medical Records Summary Information sections. These sections note down important details such as the patient’s name and date of birth, the dates that this summary will encompass, and who has conducted the Medical Record Summary. As a Medical Record Summary may often be used in legal cases, it is crucial these details are accurate so take extra care in filling them in.
Step Three. Work through the Medical Record Chronologically
Now for the main event. The large table on the first page is for the Medical Records Summary. This should be completed in chronological order, with the earliest entry at the top of the table. Add the Date and Time, the part of the patient’s medical record you have referenced (Bates numbers can go in this column if using), the provider of the service in question, and finally a short summary of the encounter.
Keep working down the table in chronological order, adding all the pertinent aspects of the patient’s medical record as they relate to the medical summary request. If you run out of space, simply copy the second page of the template as many times as you need and continue filling in the table.
Step Four. Add Page Numbers
In order to ensure this Medical Record Summary is only shared in its entirety, add in the page numbers and the total number of pages on each page. Once you have input the total page number once, it will automatically copy across to the other pages. If you have only used one page, simply put “Page 1 of 1”.
Step Five. Sign and Store Securely
The last step is to sign and add your name to the first page, and store the document securely as it contains confidential patient health information. Often, this summary would have been created in order to be shared with another provider or third party, and in this case, you should ensure it is shared securely, and that you have been authorized to disclose the patient health information contained in the Medical Record Summary.
Medical Record Summary Example (Sample)
If you’re thinking of incorporating a new template into your practice, it can be helpful to see a finished version in order to get a better idea of how the template works, and this Medical Record Summary template is no different. Take a look at our example Medical Record Summary template based on a fictional encounter with a dissatisfied patient taking legal action. Or, you can jump straight into your own Medical Record Summaries and download the blank PDF Medical Record Summary template right here.
Who Can Use this Medical Record Summary Template?
The process of making a Medical Record Summary can be very involved, and may require chasing up missing information, interpreting medical short-hand, understanding medical coding and terminology, and the ability to condense down medical documents without losing any key information. As such, the Medical Record Summary should be completed by an individual with medical expertise, as well as solid administrative and written communication skills. As such, the profession that may be best suited to this task is Legal Nurse Consultants (LNCs). LNCs are qualified nurses who act as a bridge between the healthcare and legal fields, particularly in cases of medical malpractice where expert knowledge and medical experience are needed.
That’s not to say that others cannot utilize this template in summarizing medical records, but it is crucial that the person completing this record has a medical background or knowledge of medical terminology and short-hand so they can accurately condense down key points from the medical record into the summary. Some of these professionals may include
- Registered Nurses
- Nurse Practitioners
- Medical Summarizing Consultants.
Why Is This Template Useful For Health Professionals
If you have been working as a healthcare practitioner for any significant amount of time, you have likely heard of at least one medico-legal case at your hospital or department. These cases can be time-consuming and expensive, and will undoubtedly require a lot of paperwork. Luckily, our Medical Record Summary Template can help you to provide the best possible evidence to ensure the fairest outcome of the medico-legal case. We have thought out all the details needed to ensure this template saves you time, and helps you keep all the information organized and clearly formatted.
Why Use Carepatron For Medical Record Software?
If you’ve decided to start using templates in your practice to save you time and streamline your organization, congratulations! You’ve made a great start. But there’s more where that came from.
You can find this Medical Record Summary Template and hundreds of other worksheets, note templates, intake forms, and more, in Carepatron’s comprehensive community template library. Carepatron is a state-of-the-art healthcare management software suite packed with features to save you time, here are just a few:
- Automate your patient’s SMS or email appointment reminders and reduce no-show appointments
- Manage your medical coding, billing, team calendar, and appointment scheduling
- Offer your patients their own Carepatron portal to book appointments with you, and access their own medical records
- Conduct secure telehealth consultations
And finally, connect with a community of 10,000+ healthcare professionals who have trusted Carepatron to take their practice to the next level.