Chart summary templates you can copy
Short version: 5 plain-text templates, 1 per clinical summary format, with the fields in the order the reader needs them. Copy one into your EHR's note template or smart phrase tool and delete what your setting doesn't use. Text in square brackets is for you to fill. Every field is explained, with its source, on the formats page.
Limits: Vendor facts come from each vendor's own website on 2026-11-12 and were not tested by us. Rules are summarized from the cited text; your hospital's bylaws, payer contracts and state law can ask for more.
How to use these templates
- Keep the order. Each template puts first what the reader acts on first. Moving the answer or the current status down defeats the template.
- Write "none" rather than deleting a field. "Pending results: none" tells the reader you checked. A missing field tells them nothing.
- Mark every medication with a verb: new, changed, held, restarted, stopped, unchanged. It is the fastest way to make medication reconciliation visible to the next reader.
- Give every task an owner and a date. A task with neither is a wish.
- Cite where it matters. For results and incidental findings, add the source (report date, page or document name) so the reader can check it.
Pre-visit summary template
For the clinician about to see the patient. Aim for 1 screen.
PRE-VISIT SUMMARY Patient: [name, DOB, MRN] Visit: [date], [visit reason] Prepared by: [name, role], [date] Last visit here: [date] WHAT CHANGED SINCE LAST VISIT - [ED visits, admissions, procedures, new diagnoses, each with date and source] - If nothing changed: "No interval events found in [sources checked]." ACTIVE PROBLEMS FOR TODAY 1. [problem]: [better / worse / unchanged], [1-line plan] 2. [problem]: [status], [plan] MEDICATION CHANGES - [NEW / CHANGED / HELD / RESTARTED / STOPPED] [drug, dose]: [by whom, date, why] RESULTS TO REVIEW - [test]: [value], [date], [ordered by] - Overdue: [test], due [date] OPEN LOOPS - Referrals not yet seen: [specialty, sent date] - Results pending: [test, where, expected] - Incidental findings with follow-up due: [finding, due date] CARE GAPS DUE - [screening / vaccine / monitoring lab]: last [date], due [date]
Consult summary template
For the physician who asked. The answer goes in the first 2 lines.
CONSULT: [specialty] Patient: [name, DOB, MRN] Requested by: [name], [date, time] Seen: [date, time] Urgency: [routine / urgent / emergent] QUESTION As asked: [verbatim question] As I understand it: [restated, if different] ANSWER [1 to 2 sentences] RECOMMENDATIONS 1. [specific action: drug, dose, route, duration / test, timing] 2. [ ] 3. [ ] IF THINGS CHANGE - If [finding], then [action]; call [service, number] [when]. BASIS FOR THE ANSWER HPI (relevant part): [ ] Exam: [findings and pertinent negatives] Results: [value, date] [value, date] Problems: [relevant problems] Medications: [relevant medications] Allergies: [drug: reaction] FOLLOW-UP [We will see the patient again on [date] / Signing off; call if [ ]] [Name, credentials, contact]
Transfer summary template
For the receiving team. Current status first, history second. For transfers out of the ED, the last block covers what EMTALA asks to travel with the patient.
TRANSFER SUMMARY Patient: [name, DOB, MRN] From: [unit, hospital, sending physician, callback number] To: [unit, hospital, accepting physician] Time: [date, time] REASON FOR TRANSFER [What the receiving site can do that the sending site can't] ILLNESS SEVERITY AND STATUS NOW Severity: [stable / watcher / unstable] Last vitals [time]: BP [ ] HR [ ] RR [ ] SpO2 [ ] on [ ] Temp [ ] Lines, drips, devices: [ ] Mental status: [ ] COURSE SO FAR [Presentation, working diagnosis, treatment given, response] ACTIVE PROBLEMS 1. [problem]: [status today] MEDICATIONS Current: [drug, dose, route, frequency, LAST DOSE time] Held: [drug]: [reason], [restart condition] Given in last 24 h (one-time): [drug, dose, time] ALLERGIES [drug: reaction] RESULTS [key labs with times] [imaging, including preliminary reads] Incidental findings: [finding, recommended follow-up] PENDING [test]: sent [date], result goes to [name], forwarded by [name] to [receiver] CODE STATUS AND GOALS OF CARE [status], confirmed with [patient / proxy] on [date] Decision maker: [name, relationship, phone] FOR ED TRANSFERS Transfer consent or certification: [attached / location] On-call physician who refused or failed to appear: [name, address / none] Records to follow: [what, when]
Discharge summary template
For the primary care physician, the facility and the patient. Write the hospital course by problem.
DISCHARGE SUMMARY Patient: [name, DOB, MRN] Admitted: [date] Discharged: [date] Attending: [name] Discharged to: [home / home health / SNF / other] PCP: [name] REASON FOR HOSPITALIZATION [presenting problem, admission diagnosis] DISCHARGE DIAGNOSES 1. [principal]: [status at discharge] 2. [secondary]: [status] HOSPITAL COURSE BY PROBLEM [Problem 1]: [what was done, response, status] [Problem 2]: [ ] PROCEDURES AND CONSULTS [procedure / consult service], [date]: [key finding] KEY RESULTS [test]: admission [ ] -> discharge [ ] MEDICATIONS AT DISCHARGE NEW: [drug, dose, frequency], for [indication] CHANGED: [drug] [old dose] -> [new dose], because [ ] HELD: [drug], until [condition], decided by [ ] STOPPED: [drug], because [ ] UNCHANGED: [drug, dose] PENDING AT DISCHARGE [test]: result goes to [name]; [name] will act on it by [date] INCIDENTAL FINDINGS [finding, source, date]: [recommended follow-up], owner [ ], due [date] CONDITION AT DISCHARGE [function, mental status, diet, activity] FOLLOW-UP [clinic, date, purpose] [lab or imaging, date, who orders, who reviews] WHAT THE PATIENT WAS TOLD [instructions in plain words; who was present] CODE STATUS AND GOALS OF CARE [ ]
Problem-list summary template
For anyone opening the chart. 1 line per problem; prune resolved items at least once a year.
PROBLEM LIST SUMMARY Patient: [name, DOB, MRN] Last reviewed: [date] by [name] ACTIVE | Problem | Since | Status | Current plan | Owner | | [diagnosis or finding] | [date] | [better / worse / unchanged] | [1 line] | [clinician] | WATCH (not active, needs follow-up) | [incidental finding or risk] | [date] | [due date] | [owner] | RESOLVED (last 12 months) | [problem] | [resolved date] |
Before you send it: a 6-line check
- Does the first screen answer the reader's question?
- Does every medication carry a verb?
- Does every pending result have a name next to it?
- Is every incidental finding carried forward with a due date?
- For transfers and discharges: is code status stated, with the date it was confirmed?
- Could the reader find the source of every result you cite?
The longer version, by format and with the evidence behind each item, is the omission checklist. To see the templates filled in, go to the worked examples.