Medical Record Summary

How to use this Medical Record Summary Template 

Our free medical records summary template is straightforward to use, but follow these simple steps to ensure you understand how to complete each section.

Step 1: Download the Medical Record Summary Template

The first step is to download the Medical Record Summary Template. You can download the free PDF version using the link on this page or find it and many others from 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 summary report and number them once you are finished.

Step 2: 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 essential details such as the patient's name and date of birth, the dates this summary will encompass, and who has conducted the summary. Knowing the patient's personal history is essential in documenting incidents and previous treatments, supporting medical evidence, and thorough evaluations. As a medical record summary may often be used in legal cases as medical evidence, these details must be accurate, so extra care must be taken in filling them in.

Step 3: Work through the medical record chronologically

The large table on the first page is for a healthcare professional to summarize medical records. This should be completed chronologically, with the earliest entry at the top of the table. Add the date and time, the part of the patient's medical record you referenced, the provider of the service in question, and a summary of the encounter. 

Keep working down the table chronologically, adding all the pertinent aspects of the patient's medical record related to the medical summary request.

Step 4: Add page numbers 

To ensure this Medical Record Summary Template is only shared in its entirety, add the page numbers and the total number of pages on each page. Put "Page 1 of 1" if you have only used one page. In our medical record sample, two pages were used by the healthcare professional.

Step 5: 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 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's health information. Conducting medical record reviews regularly is also essential.

Who can use this Medical Record Summary Template?

Making a medical record summary can be very involved and may require chasing up missing information, some complex medical information, interpreting medical shorthand, understanding medical coding and terminology, and condensing medical documents without losing any key information.

As such, an individual with medical expertise and solid administrative and written communication skills should complete the Medical Record Summary Template. 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. Still, the person completing this record must have a medical background or knowledge of medical terminology and shorthand to accurately condense critical points from the medical record into the summary. Some of these healthcare professionals may include:

1. Registered nurses
2. Physicians
3. Nurse practitioners
4. Medical summarizing consultants

Why is this template useful for medical 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 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. You can check our sample medical records summary.

Benefits of using the Medical Record Summary Template 

Here are just a few benefits of using our medical records summary sample and template to summarize your patient's medical record:

Pre-formatted

Condensing down what can be years of medical records into a single, chronological summary can be time-consuming enough without having to worry about formatting as well! Our interactive PDF template comes pre-formatted in a simple, clearly laid out table with all the headings and information you need to provide. We also have a sample medical summary to help you understand the structure and elements of an effective summary.

Improves your organization

Even if there is no active medico-legal case requiring that you provide a summary of a patient's medical record, creating a medical record summary for patients whose medical records have become disorganized or fragmented can be a good idea. 

Improves readability

Speaking of staying organized, your colleagues will thank you for utilizing a laid-out template for your medical record summaries. This template will make it much easier for others to read and understand this document. They can quickly get the necessary information using the chronological table, date, and provider columns.