Chart Note Template

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. Chart notes act as a chronological journal of relevant updates for your patient.

Although often used by ward nurses, many members of a patient's care team use and can benefit from chart notes, such as nurses, resident doctors, overnight shift staff, allied health workers, care workers, and resident or trainee healthcare workers. These notes and their corresponding chart templates serve as supplementary resources to a medical chart, soap notes, etc.,

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. It is a useful resource for keeping you and your team organized. Not only is our template pre-formatted and laid out for those who aren't in a rush, but it's also customizable for any additional notes you may have regarding the patient that you think other healthcare providers must know about.

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 take chart notes with Carepatron's handy medical chart notes template:

Step 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.

Step 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, past medical history, family history, room number, and other relevant information that may aid with completing the chart notes and getting to know the condition better for context. 

Step 3: Enter the date, 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. 

Step 4: Note your patient's progress

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.

Step 5: Sign the note, and store it securely

Once you've finished writing the progress of your patient, 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.

Should you need a guide on what to write in your blank Chart Note Template, feel free to reference our provided sample chart notes or chart note example.

Benefits of using Chart Notes templates

There's no doubt that Chart Notes are a valuable tool and resource used by nurses and other medical healthcare providers. In addition, having templates on hand when making these notes is just as important because of the following benefits:

Less mental load

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.

Keep your chart notes organized

With space for the date, time, and signature of the chart notes entry- you won't be chasing up the writer of an accidentally anonymous note or trying to piece together a timeline from many different notes again.

Improve communication between your staff members

A simple chart notes template can create a dialogue between your patient's care team members. Any important updates observed by one team member can be noted down and seen, in chronological context, by another team member who sees the patient after them.

Support handwritten or digital progress notes

This PDF chart template can be printed and filled in by hand whenever someone needs to add an entry or kept digital. Be careful about overwriting file versions if using this template digitally, though, as many people accessing the same template simultaneously could result in information being accidentally lost.

Maintain accountability

By ensuring each entry is signed and dated, you ensure that every entry is traceable and if further information on a particular entry is needed, you can find the author of the chart notes entry in question. 

Keep notes well-formatted

Notes with multiple authors may quickly become chaotically formatted! Using a chart notes template with premade formatting saves you time formatting your own notes. It is also important that these chart notes can be easily shared and understood by third parties such as insurance companies, and using a well-formatted template will help ensure others can easily follow your notes.

Encourage collaboration

Having a template that clearly shows how to add an entry to the patient's 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.