7 Real-Life Medical Scribe Note Examples to Make Documentation Effortless

Every clinician knows the feeling: back-to-back appointments and the looming mountain of documentation.

What if you could manage your documentation so efficiently that you can relax, pursue your hobbies, or simply enjoy dinner with your family without the shadow of pending paperwork?

Learning from real-life medical scribe note examples can make this your reality. The more examples you study, the more you can improve your note-taking skills and fast-track documentation. 

The result? Clear and accurate medical notes, created in minutes. 

That’s why we’ve curated seven examples of medical scribe notes with tips to use each type of documentation for the right use case. You'll find real-life examples and a list of elements to structure each note.

The 7 most common types of medical scribe notes

Healthcare providers already have enough on their plates without the added pressure of inefficient documentation. 

With burnout rates climbing—research indicates that 49% of providers face burnout—it's time to investigate the documentation process.

We’ll help you steer away from this stress with seven examples of medical scribe notes, each one with hands-on guidelines.

1. History and physical (H&P) examination 

When it’s used

• New patient consultations or hospital admissions
• Preoperative assessments and evaluations
• Complex or chronic cases requiring follow-up visits

An H&P is a comprehensive documentation of a patient’s health issues when they visit a physician for the first time. Medical scribes also create these notes during follow-up medical checks.

Here’s a quick snapshot of what these notes typically look like:

When creating H&P notes, it's crucial that you:

• Prioritize clarity in the HPI details: Chronologically document a patient's symptoms, including onset, intensity, duration, and potential triggers. Highlight any factors that alleviate their symptoms.
• Contextualize the information: Provide more insights about the recorded data based on the patient’s stated issue. For example, “Patient is a 33-year-old male with a history of chronic GERD, manifesting as severe epigastric pain after meals.”
• Tie assessments to the CC: All clinical findings, including results from the PE and ROS, should be evaluated based on the primary complaint. That said, don’t skip additional observations that may seem unrelated to the condition.
• Document specific treatment timeframes: Note the exact dosage,  frequency, and follow-up routines for prescribed medication. For example, "Prescribed 10 mg omeprazole daily for 3 weeks. Follow up in 1 week."

Additionally, you want to include the treatment or management steps for confirmed diagnoses. This simplifies your communication with patients and informs them of therapeutic or preventive lifestyle changes as soon as possible.

Key sections typically recorded in H&P notes

Section	Details to be included
Chief complaint (CC)	The primary reason/symptom causing the patient to seek medical care should be recorded in the patient’s words.
History of present illness (HPI)	A detailed record of the patient’s present condition, including a chronological description of how the symptoms developed.
Past medical history (PMH)	A review of the patient’s past surgeries, illnesses, or chronic conditions.
Medications & allergies	Known allergies, currently prescribed medication, ongoing supplements (if any).
Family history (FH)	A detailed background of significant health problems or illnesses in the patient's family.
Social history (SH)	A summary of the patient’s alcohol/tobacco consumption, substance use (if applicable), and lifestyle (activity levels/exercise routines).
Review of systems (ROS)	A clinical review/examination of all bodily functions and systems to uncover any undiagnosed issues.
Physical examination (PE)	The results/findings from a standard examination performed by the physician.
Assessment and plan (A&P)	The physician evaluates the patient's condition and the planned course of action (treatment/specialist referral/etc.).

2. Consultation notes

When it’s used

• To further evaluate a patient’s condition or confirm a diagnosis
• For seeking specialist expertise or guidance on complex medical cases

Consultation notes are typically created when the primary physician wants to seek the clinical opinion of a specialist in assessing or treating a patient’s condition.

Consultation notes must be concise while presenting all the relevant details to the specialist.

A perfect example would look something like this:

Here are some points to remember when creating consultation notes:

• Start with the exact reason: Specify the question or issue the referring physician wants the specialist to address. This gives the specialist a clear direction to assess the patient's condition.
• Provide a detailed but concise patient history: Include only the most relevant clinical information from the patient's medical history. Comorbid conditions or past surgeries related to the illness all fall in this category.
• Inform the consultant about previously administered PEs: Include data from already administered tests to make the referral more effective. You can also present any findings from your ROS report related to the referral question.

It's best to update the information based on the physician's recommended timelines for complex cases. If the patient's condition is critical, mention it on the note.

Key sections typically recorded in consultation notes

Section (Pre-surgery)	Details to be included
Consultation reason	The reason behind the attending physician seeking the consultant's expertise (potential complications based on PMH/surgery risks).
History & physical examination	Information that would be relevant to the specialist, including the results from any previous medical tests.
Assessment	The consultant’s clinical opinion on the patient’s symptoms or condition.
Plan	Recommendations for further diagnostic tests, examinations, treatment plans, or management strategies.

3. Diagnostic test or lab result documentation

When it’s used

• While ordering diagnostic assessments
• During routine patient visits
• For monitoring ongoing treatment plans or reviewing disease progression

One of the core responsibilities of a medical scribe is documenting the findings from diagnostic or lab tests. This also includes noting and interpreting results from such clinical examinations.

Here's what diagnostic or lab results look like in most cases:

When recording the results from a diagnostic or imaging report, ensure that you:

• Organize test information: Structure the data on the administered test for maximum clarity. Consider organizing/presenting the information based on test types or using concise headings (Radiology Report/CBC/etc).
• Contextualize the results: While noting the test results, always contextualize the findings based on clinical significance. For example, "Elevated ALT and AST indicate liver injury. Viral hepatitis suspected."

You also need to record follow-up instructions. For example, if the lab results suggest a need for further testing, you must note specific actions to be taken next. Here’s an example: "Repeat CBC in 2 weeks to assess for any improvements in hemoglobin level."

Key sections typically recorded in consultation notes

Section (Pre-surgery)	Details to be included
Test ordered	The specific name of the administered lab test (CBC/OGTT).
Reason for ordering the test	A brief but detailed clinical explanation for why the patient had to undergo the diagnostic examination, including suspected conditions.
Test order date and time	The exact date and time when the test was requested and administered.
Patient identification and sample details	The patient's full name, date of birth, medical record number, and concise details on the sample taken and the collection method.
Test results	Specific measurements of the results in numerical value with comparative reference ranges, or qualitative results, if applicable (positive/negative).
Clinical interpretation of test results	The physician’s professional analysis of the lab results, including any detected abnormalities.
Treatment or follow-up plan	Recommendations for any further diagnostic testing, medication, or intervention strategy.

4. Progress notes

When it’s used

• In follow-up consultations for chronic conditions (diabetes/epilepsy/etc.)
• During routine clinic rounds 
• For systematically monitoring treatment efficacy or progression of the condition

Progress notes record a patient's current clinical status, response to ongoing medical care, or changes in their existing conditions/symptoms.

Here are three main types of progress notes:

• SOAP: Subjective, Objective, Assessment, and Plan notes document a patient’s progress over time in a structured format. 
• DAP: Data, Assessment, and Plan format combines the patient’s subjective information and the physician’s objective assessment into one section (Data).
• DART: Data, Action, Response, and Treatment notes are usually applied in a psychiatric setting.

Progress notes include extensive details about a patient’s current mental and physical health.

Here are a few tips to create such notes:

• Be consistent: Typically, progress notes are created daily. You should make sure that the data is updated consistently and reflects the patient’s present clinical status. This prevents errors in treatment administration and prolonged recovery periods.
• Track all changes: Record any new developments in the patient's condition since the last progress note. This can be as simple as "Patient reports less pain after today's physical therapy session."
• Add actionable updates for each subsequent note: Each progress note you create should also clearly define follow-up actions. For instance, “Patient’s culture report confirms amoxicillin sensitivity. Discontinue IV antibiotics from hereon.”

To get a better understanding here, take a look at this progress note (in SOAP format):

Key sections typically recorded in progress notes

Section (Pre-surgery)	Details to be included
Patient identification	Key details about the patient (full name/age/date of birth/medical record number).
Subjective data	The patient’s primary reason for the visit or consultation (symptoms/condition).
Objective data	Core medical data of the patient, including blood pressure, temperature, heart rate, and the results of any physical examinations.
Assessment	The diagnosis made by the attending physician and a detailed summary of the patient’s present clinical condition.
Plan	Any remaining diagnostic tests to be administered, planned treatment, or referral recommendations.
Medications	Prescribed medication, including precise details on dosage and frequency. This section also covers any changes made to previous medication plans.
Treatment response	A detailed assessment of any improvement or worsening of the patient’s condition, including side effects or adverse drug reactions.
Provider identification	The name and title of the attending physician or healthcare provider.

5. Preoperative and postoperative evaluation notes

When it’s used

• Before undergoing surgery to review the patient’s overall health
• To determine the patient’s readiness for the procedure

Before surgical procedures, medical scribes create a comprehensive health record for a patient. This includes their medical history, test results from physical examinations or diagnostic tests, and the proposed operative method.

These notes are updated post-surgery to include the patient’s immediate health/clinical status and an assessment of the recovery period.

While preoperative and postoperative evaluation notes are created asynchronously, you can consolidate these documents to provide a comprehensive overview of the patient's condition. 

Here’s a part of a preoperative evaluation note:

Here are three of the most important points to remember when creating preoperative/postoperative evaluation notes:

• Detail all risk factors: Document all elements that can pose a risk to the patient during the procedure. This includes comorbidities (diabetes/hypertension), medications (anticoagulants, etc), and the patient's functional state.
• Record instructions for specific operative difficulties: If there are patient-specific challenges (history of difficult intubation, etc), clearly record them in your notes. Also, detail the physician’s recommendation for managing such concerns.
• Elaborate on postoperative complications: It's crucial to record, contextualize, and detail the next steps for post-surgery concerns. For example, "Patient's postoperative fever is likely due to atelectasis. Start low-dose heparin for DVT prophylaxis."

It also helps to document expected recovery milestones and the patient's current progress. A straightforward example would be: "Patient can move with minimal assistance. Follow up in 1 week for suture removal."

Key sections typically recorded in preoperative and postoperative notes

Section (Pre-surgery)	Details to be included
Patient history	An assessment of the patient’s condition. This section also covers risk factors (excessive bleeding/cardiac arrest/etc.), medications, and any potential comorbidities that can affect the success of the surgery.
Physical examination	Results from a standard clinical examination, with a specific focus on body systems relevant to the operation.
Operative plan	Any necessary preoperative instructions for the patient and the confirmation of the surgical procedure.
Section (Post-surgery)	Details to be included
Immediate postoperative course	A comprehensive documentation of the patient’s clinical state immediately after the procedure.
Recovery assessment	The patient’s progress, improvement in their diagnosed condition, and postoperative complications during the recovery period.

6. Operative or procedure notes

When it’s used

• After any surgical (invasive and non-invasive) operation 
• Post non-surgical interventions (biopsies/endoscopies/etc.)

During surgical operations, scribes have to note down details of the procedure, like its exact steps, potential complications, and any relevant medical findings.

Procedure notes are often the most challenging to create. This is primarily due to the extensive technical knowledge they require.

Here are three tips to make things easier on yourself:

• Be specific about operative steps: Accurately note every critical surgery step. This includes the surgical approach, specific incisions made, and technique variations.
• Document any intraoperative findings: Record any surgical complications and corrective actions in detail in your notes. For instance, "Adhesions were found in the lower left quadrant during the laparotomy. Additional dissection was required".
• Use clear and concise language: While operative notes are significantly technical, avoid any unnecessary jargon and be precise about what was performed. Here's an example: "Performed a right nephrectomy due to suspected renal malignancy."

For a better reference, here’s a basic sample of a procedure note:

Key sections typically recorded in operative or procedure notes

Section	Details to be included
Preoperative diagnosis	Precise details on the condition being surgically operated on.
Procedure performed	A comprehensive record of the surgical procedure performed.
Clinical findings	Any relevant medical observations made by the surgeon during the procedure.
Intraoperative complications	Details on any complications during the surgical operations (if applicable).
Postoperative diagnosis	Any changes or improvements in the patient's clinical status after the surgery.
Patient disposition	Documentation of the patient’s transfer to recovery or the next stage of clinical care.

7. Discharge summaries

When it’s used

• Upon discharge from a hospital or an in-patient facility

Before a patient is discharged, you have to document the treatment course administered, including a final diagnosis. These notes also mention follow-up care instructions for managing chronic conditions.

Here’s a sample of what these discharge summaries typically look like:

Consider these tips when creating discharge summaries:

• Record and summarize the entire course: Detail all interventions during the hospitalization period. Additionally, maintain an accurate record of the patient's progress and condition upon discharge.
• List all prescribed medications: Comprehensively list the administered and ongoing medication. Also, elaborate on any instructions. For example, "Prescribed 500 mg amoxicillin once a day for 1 week. Take with food to reduce GI issues.”
• Clarify post-discharge plans and follow-up actions: Note any referrals for physical therapy, community resources, or post-discharge recommendations. For instance, "Consultation with cardiology in 2 weeks to assess postoperative recovery".

Another tip would be to document patient communication in your notes. 

Confirm that the patient understands the discharge/follow-up plan in its entirety. This can be reflected in your records as a simple "verbalized understanding with patient."

Key sections typically recorded in discharge summaries

Section	Details to be included
Patient admission details	Reason for patient admission, clinical diagnosis, administered treatment, and management/intervention strategy.
Hospitalization course	A detailed overview of the patient's response to treatment, their progress, operative procedures (if applicable), and potential complications.
Discharge diagnosis	Final diagnosis upon patient discharge (details on the condition’s progress).
Post-discharge plan	Follow-up instructions for the patient, prescribed medication, necessary management tips, and any lifestyle changes.

Make your life (and documentation) easier with an AI scribe

Imagine the relief of ending a packed day at the clinic and realizing you don’t have to spend hours charting every visit. 

That’s what life looks like with Freed. 

Freed is built to win back time and make life easier for clinicians like you. 

You can record patient conversations with the click of a button and Freed will prepare detailed and clinically accurate notes based on your preferences.

You can customize your preferences for preparing notes. You can adjust the length, choose the consent language, and more. 

Use the “Magic Edit” option to make changes across the document in one go. For example, if you want to change the patient’s name, write: “Change patient name to Jane Doe.”

Besides, every time you edit a note, Freed learns your style and incorporates these changes in future documents. 

Simplify medical documentation for yourself

Creating accurate clinical notes has always been a tedious task. 

But not anymore. 

This article gives you a handy list of medical scribe note examples with actionable tips to create these documents effortlessly. 

AI scribes like Freed take away the stress of manually documenting every patient visit. Simply record all interactions and leave it on Freed to create notes instantly, accurately. 

Sign up for a free trial to see it yourself.