Every patient will require a medical note. It is an important record of the patient’s health condition that records the types of treatment and medication for any health condition that the patient may had or have.
The medical note helps the medical team to monitor the patient’s medical condition accurately so that the health of the patient improves.
A medical note is similar to the patient’s welfare record. It could be updated by an assigned nurse or medical assistant to a patient. The medical notes allow the attending physician to be reminded and to keep on the right track on diagnosis and analysis on the patient as he may be attending to many patients. It is to ensure that no wrong prescription or diagnosis is applied. The medical notes assist the nurse, medical assistant or physician to care for the patients by referring to and recording the patient’s medical condition over time.
A medical note template would contain the following information:
* Medical provider’s name and status
* Patient’s Name
* Patient’s reference number
* Patient’s background & medical history
* Patient’s health condition
* Patient’s current diagnosis
* Patient’s treatments
* Patient’s counseling sessions
* Rehab therapy
* Short term goals
* Long term goals
* Special Instructions
* Diet & Nutrition recommendation
* Attending physician
There can be other pieces of relevant information on a medical note depending on the health institution.
Consider the attached sample template for your convenience.