Medical Notes Guide: Types, Examples & Templates
Everything you need to know about medical documentation in 2026. Learn all note types, writing best practices, and how AI is transforming clinical documentation.
What Are Medical Notes?
Medical notes (also called clinical notes, patient notes, or physician notes) are the written or electronic documentation that healthcare providers create to record patient encounters. They capture everything from symptoms and diagnoses to treatments and follow-up plans.
Medical notes form the backbone of the legal medical record. They document the care provided, support clinical decision-making, enable communication between providers, and serve as evidence of the services rendered for billing purposes.
Why Medical Notes Are Critical
The Golden Rule of Documentation
"If it wasn't documented, it didn't happen." This legal principle underscores why thorough, accurate documentation is essential. Your notes should tell the complete clinical story and support your medical decision-making.
Types of Medical Notes
Healthcare uses various note types for different purposes. Understanding when to use each ensures appropriate documentation for every clinical scenario.
SOAP Notes
Structured format organizing clinical information into Subjective, Objective, Assessment, and Plan sections.
Used by: All healthcare providers
Setting: Outpatient visits, consultations, follow-ups
Key Elements:
- Chief complaint
- HPI
- Physical exam
Progress Notes
Document ongoing patient care, tracking changes in condition and treatment response over time.
Used by: Physicians, nurses, therapists
Setting: Hospitalizations, ongoing treatment, therapy sessions
Key Elements:
- Interval history
- Current status
- Response to treatment
H&P (History & Physical)
Comprehensive documentation of patient medical history and physical examination findings.
Used by: Physicians, PAs, NPs
Setting: Hospital admissions, new patient evaluations, pre-operative
Key Elements:
- Complete medical history
- Review of systems
- Full physical exam
Discharge Summary
Summarizes hospitalization including diagnosis, treatment, and post-discharge instructions.
Used by: Physicians, hospitalists
Setting: Hospital discharge, rehab discharge, SNF discharge
Key Elements:
- Admission diagnosis
- Hospital course
- Discharge medications
Operative Notes
Detailed documentation of surgical procedures including technique and findings.
Used by: Surgeons, surgical assistants
Setting: Operating rooms, surgical centers
Key Elements:
- Procedure performed
- Operative technique
- Intraoperative findings
Consultation Notes
Document specialist evaluation and recommendations for referring providers.
Used by: Specialists, consultants
Setting: Specialty consultations, second opinions
Key Elements:
- Reason for consult
- Specialist assessment
- Recommendations
Nursing Notes
Document nursing assessments, interventions, and patient responses.
Used by: RNs, LPNs, nursing staff
Setting: Hospitals, clinics, home health, long-term care
Key Elements:
- Nursing assessment
- Interventions
- Patient response
Psychiatric Notes
Document mental health evaluations, therapy sessions, and psychiatric treatment.
Used by: Psychiatrists, psychologists, therapists
Setting: Mental health clinics, therapy sessions, inpatient psych
Key Elements:
- Mental status exam
- Risk assessment
- Therapy interventions
Medical Note Writing Principles
Follow these core principles to ensure your documentation is legally sound, clinically useful, and compliant with regulatory requirements.
Accuracy
Document facts as observed or reported. Avoid assumptions or interpretations without evidence.
Example: Write "Patient reports pain 7/10" not "Patient is in severe pain"
Timeliness
Document as close to real-time as possible. Delayed entries should be marked as "late entry."
Example: Complete notes within 24 hours of encounter; ideally same-day
Objectivity
Use neutral, professional language. Avoid judgmental terms or personal opinions.
Example: Write "Patient has not filled prescriptions x3 months" not "Patient is non-compliant"
Completeness
Include all clinically relevant information, including pertinent negatives.
Example: Document "Denies chest pain, shortness of breath, or palpitations" for cardiac evaluation
Clarity
Use clear, unambiguous language. Avoid abbreviations that could be misinterpreted.
Example: Write "daily" instead of "QD" which could be confused with other abbreviations
Authentication
Every entry must be signed, dated, and time-stamped by the author.
Example: Electronic signature with credentials, date, and time of entry
Documentation Formats Compared
Choose the right format based on your specialty, setting, and documentation needs.
| Format | Sections | Best For | Pros/Cons |
|---|---|---|---|
| SOAP | SubjectiveObjectiveAssessmentPlan | General clinical encounters, outpatient visits | + Universal, logical flow, supports billing - Can be rigid for some specialties |
| DAP | DataAssessmentPlan | Mental health, therapy sessions | + Streamlined, combines subjective/objective - Less detailed than SOAP |
| BIRP | BehaviorInterventionResponsePlan | Behavioral health, counseling | + Focuses on therapeutic interventions - Specific to mental health settings |
| Narrative | Free-form chronological documentation | Complex cases, detailed case summaries | + Flexible, captures nuance - Can lack structure, harder to review quickly |
| Problem-Oriented | Problem listPer-problem documentation | Multiple chronic conditions, complex patients | + Organizes by problem, comprehensive - Can be time-consuming |
Medical Note Example
Here's a complete example of a well-written medical note for an outpatient visit.
Visit Type: Follow-up Visit
Setting: Primary Care
PATIENT INFORMATION
Patient: Jane Smith | DOB: 03/15/1978 | MRN: 123456
Date: 12/19/2025 | Provider: Dr. Johnson, MD
SUBJECTIVE
CC: "I need to check my blood pressure and refill my medications."
HPI: 46-year-old female with HTN and T2DM returns for routine follow-up. Reports good medication compliance. Home BP readings averaging 128/82. Denies headaches, vision changes, chest pain, or SOB. Blood sugars fasting 110-130 per home monitoring. No hypoglycemic episodes. Last A1c 7.2% three months ago.
ROS: Negative for headache, vision changes, chest pain, palpitations, dyspnea, polyuria, polydipsia, numbness/tingling in extremities.
Medications: Lisinopril 20mg daily, Metformin 1000mg BID, Atorvastatin 20mg daily.
Allergies: Penicillin (rash)
OBJECTIVE
Vitals: BP 126/78 (left arm, sitting), HR 72, RR 14, Temp 98.2°F, SpO2 99% RA, Wt 168 lbs, Ht 5'5", BMI 28.0
General: Alert, oriented, well-appearing, no acute distress.
CV: Regular rate and rhythm, no murmurs, rubs, or gallops. No peripheral edema. Pedal pulses 2+ bilaterally.
Lungs: Clear to auscultation bilaterally.
Extremities: No lesions, intact sensation to monofilament bilateral feet.
ASSESSMENT
1. Essential hypertension (I10) - Well controlled on current regimen. BP at goal <130/80.
2. Type 2 diabetes mellitus without complications (E11.9) - Fair control. A1c target <7%. No evidence of neuropathy, nephropathy, or retinopathy.
3. Hyperlipidemia (E78.5) - On statin therapy. Due for lipid panel.
PLAN
1. Hypertension:
- Continue lisinopril 20mg daily
- Continue home BP monitoring
- Lifestyle counseling: DASH diet, sodium restriction, regular exercise
2. Type 2 Diabetes:
- Continue metformin 1000mg BID
- Order HbA1c, BMP (for renal function)
- Diabetic foot exam performed today - normal
- Ophthalmology referral for annual diabetic eye exam
3. Hyperlipidemia:
- Continue atorvastatin 20mg daily
- Order fasting lipid panel
Patient Education: Reviewed importance of medication compliance, diet, exercise, and regular monitoring. Patient verbalized understanding.
Follow-up: 3 months or sooner if concerns.
Electronically signed by: Dr. Sarah Johnson, MD
Date/Time: 12/19/2025 14:32 EST
2026 Medical Documentation Trends
The healthcare documentation landscape is evolving rapidly. Here are the key trends shaping medical notes in 2026.
AI-Powered Documentation
Ambient AI scribes listening to encounters and auto-generating notes, reducing physician documentation burden by 70%+.
Voice-First Documentation
Natural language processing enabling providers to dictate notes conversationally rather than using structured templates.
Interoperability Standards
TEFCA and FHIR standards enabling seamless health information exchange across EHR systems.
Patient-Generated Data Integration
Wearables and patient-reported outcomes automatically flowing into medical records.
Reduced Documentation Burden
AMA 25x5 Initiative pushing to reduce documentation burden by 75%, with CMS supporting simplified requirements.
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Frequently Asked Questions
What are medical notes?
Medical notes are written or electronic documentation created by healthcare providers to record patient encounters, health information, treatments, and clinical decisions. They form the legal medical record and are essential for continuity of care, billing, legal protection, and quality improvement.
What are the main types of medical notes?
The main types include: SOAP notes (Subjective, Objective, Assessment, Plan), Progress notes, H&P (History and Physical), Discharge summaries, Operative/procedure notes, Consultation notes, Nursing notes, and specialty-specific documentation like psychiatric evaluations or therapy notes.
What is the difference between medical notes and progress notes?
Medical notes is a broad term encompassing all clinical documentation. Progress notes are a specific type of medical note that document ongoing patient care, typically written during hospitalizations or follow-up visits to track changes in condition and treatment response over time.
How should medical notes be written?
Medical notes should be accurate, timely, objective, and complete. Use clear language, standardized terminology, and structured formats like SOAP. Document as close to real-time as possible, include pertinent positives and negatives, and ensure all entries are authenticated with date, time, and signature.
Can AI write medical notes?
Yes, AI medical scribes like PatientNotes can automatically generate medical notes from patient encounters. The AI listens to the conversation, extracts clinical information, and creates properly formatted documentation. Providers review and approve the notes, saving 2+ hours daily while maintaining accuracy.
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