Free Clinical Summary Template & Sample
"Will I ever get these clinical summaries done?"
That's a song sung by 77.42% of health professionals. Survey respondents said that they are finishing work later than desired due to excessive documentation tasks.
That's why we've put together a simple template to help you work faster as well as provide some insights on using AI to improve your workflow.
Clinical summary: Patient information at a glance
Clinical summaries are probably super familiar to you. However, we'll go over their definition briefly before looking at some templates.
A clinical summary is a summarized overview of a patient's medical history, including diagnoses, medications, and lab results. It is usually used to provide a quick reference for healthcare providers to access important information about a patient.
Clinical summary
Click to download our free treatment summary template.
Template section breakdown: What makes up a clinical summary?
Each medical/healthcare institution has its own mix of sections, so you'll need to adapt it to your specialty and experience.
For example, mental health summary templates can vary, with less focus on physical examinations.
However, clinical summaries tend to have some key sections.
Here are some sections you can choose to include and what they might contain:
Patient information
What's in it:
- Patient name
- Date of birth (DOB)
- Medical record number (MRN)
- Other identifying details
Why it matters: These basics help prevent mix-ups and ensure safe prescribing.
Chief complaint & history of present illness (HPI)
What's in it:
- Reason for visit
- Onset
- Location
- Duration
- Characteristics
- Aggravating/Alleviating factors
- Related symptoms
- Treatment attempted
- Progression
Why it matters: Set the goal for the visit and help form your initial and differential diagnoses
Past medical history
What’s in it:
- Chronic conditions
- Surgeries/hospitalizations
Why it matters: Past conditions shape today’s diagnosis and care decisions.
Medications
What's in it:
- Current medications
- Dose
- Frequency
Why it matters: Identify potential drug interactions, guides prescribing decisions, and evaluate adherence.
Allergies
What's in it:
- Known past allergies
- Nature of reactions
Why it matters: Patient safety first and foremost — especially to avoid prescribing or administering contraindicated medications
Review of systems (ROS)
What’s in it:
- A quick system-by-system scan of symptoms.
Why it matters: Catches relevant details missed in the main complaint.
Physical examination
What's in it:
- Vital signs
- General appearance
- System-specific findings
Why it matters: These observations are tailored to the chief complaint to support clinical decision-making and continuity of care.
Labs and imaging
What’s in it:
- Any tests conducted
- Test results and findings
Why it matters: Links clinical signs with objective data.
Assessment
What's in it:
- Diagnosis
- Differential diagnoses
Why this matters: Summarizes your clinical reasoning into a clear picture
Plan
What's in it:
- Treatment plan
- Medications (new or modified)
- Recommendations and referrals
- Follow-up, next steps, and expected outcomes
- Patient education
Why it matters: Gives team members and the patient a shared path forward
Signature
What's in it:
- Your name
- Signature
- Date
Why it matters: Closes the loop, confirms accuracy, and keeps things compliant.
Completed clinical summary sample
Let's have a look at a specific example: a classic knee pain case.
Why clinical summaries matter
Thankfully, all this documentation isn't a waste of time. A treatment summary actually helps your patients. Here's how:
- Improved communication: Keep the care team aligned and reduce miscommunication during transitions.
- Legal and regulatory requirements: Ensure compliance with healthcare regulations and standards — reducing liability.
- Enhanced patient engagement: Allow patients to understand and trust their care plan.
- Time efficiency: Streamline the clinical documentation process and reduce errors.
AI Scribes: The future of clinical summaries?
While scanning the above example, did you notice that it could quickly become long-winded?
This is the key issue — in 2022, the average time spent generating clinical documentation increased by 25% over the last 7 years.
This begs the question: Is there a solution?
Our answer to you is: Yes! AI scribes.
AI scribes are already lightening the documentation load—no more typing marathons.
What are AI scribes?
AI scribes are virtual assistants that use artificial intelligence to document patient encounters in real time. They listen to conversations between providers and patients, analyze the information, and create accurate and comprehensive clinical summaries.
Here are a few ways AI scribes can serve as an alternative or supplement to your current system:
- Real-time documentation: Capture patient encounters in real time and generate summaries that reduce the burden of manual data entry. This not only saves time but also ensures key details are not lost.
- Increased accuracy: Accurately transcribe complex medical terminology, significantly reducing transcription errors.
- Time savings: Free up valuable time that practitioners can spend with patients — or off the clock.
- Scalability: Scale on demand without compromising the quality of documentation.
Go beyond templates
Templates are a great start—but they still rely on you doing the work.
What if you could skip the typing entirely?
Freed is your AI medical scribe that listens, transcribes, and drafts your clinical notes—so you can focus on care, not clicks. Clinical summaries? Done while you talk.
Try Freed free and see how fast documentation can really be.
Free Clinical Summary Template & Sample
Table of Contents
"Will I ever get these clinical summaries done?"
That's a song sung by 77.42% of health professionals. Survey respondents said that they are finishing work later than desired due to excessive documentation tasks.
That's why we've put together a simple template to help you work faster as well as provide some insights on using AI to improve your workflow.
Clinical summary: Patient information at a glance
Clinical summaries are probably super familiar to you. However, we'll go over their definition briefly before looking at some templates.
A clinical summary is a summarized overview of a patient's medical history, including diagnoses, medications, and lab results. It is usually used to provide a quick reference for healthcare providers to access important information about a patient.
Clinical summary
Click to download our free treatment summary template.
Template section breakdown: What makes up a clinical summary?
Each medical/healthcare institution has its own mix of sections, so you'll need to adapt it to your specialty and experience.
For example, mental health summary templates can vary, with less focus on physical examinations.
However, clinical summaries tend to have some key sections.
Here are some sections you can choose to include and what they might contain:
Patient information
What's in it:
- Patient name
- Date of birth (DOB)
- Medical record number (MRN)
- Other identifying details
Why it matters: These basics help prevent mix-ups and ensure safe prescribing.
Chief complaint & history of present illness (HPI)
What's in it:
- Reason for visit
- Onset
- Location
- Duration
- Characteristics
- Aggravating/Alleviating factors
- Related symptoms
- Treatment attempted
- Progression
Why it matters: Set the goal for the visit and help form your initial and differential diagnoses
Past medical history
What’s in it:
- Chronic conditions
- Surgeries/hospitalizations
Why it matters: Past conditions shape today’s diagnosis and care decisions.
Medications
What's in it:
- Current medications
- Dose
- Frequency
Why it matters: Identify potential drug interactions, guides prescribing decisions, and evaluate adherence.
Allergies
What's in it:
- Known past allergies
- Nature of reactions
Why it matters: Patient safety first and foremost — especially to avoid prescribing or administering contraindicated medications
Review of systems (ROS)
What’s in it:
- A quick system-by-system scan of symptoms.
Why it matters: Catches relevant details missed in the main complaint.
Physical examination
What's in it:
- Vital signs
- General appearance
- System-specific findings
Why it matters: These observations are tailored to the chief complaint to support clinical decision-making and continuity of care.
Labs and imaging
What’s in it:
- Any tests conducted
- Test results and findings
Why it matters: Links clinical signs with objective data.
Assessment
What's in it:
- Diagnosis
- Differential diagnoses
Why this matters: Summarizes your clinical reasoning into a clear picture
Plan
What's in it:
- Treatment plan
- Medications (new or modified)
- Recommendations and referrals
- Follow-up, next steps, and expected outcomes
- Patient education
Why it matters: Gives team members and the patient a shared path forward
Signature
What's in it:
- Your name
- Signature
- Date
Why it matters: Closes the loop, confirms accuracy, and keeps things compliant.
Completed clinical summary sample
Let's have a look at a specific example: a classic knee pain case.
Why clinical summaries matter
Thankfully, all this documentation isn't a waste of time. A treatment summary actually helps your patients. Here's how:
- Improved communication: Keep the care team aligned and reduce miscommunication during transitions.
- Legal and regulatory requirements: Ensure compliance with healthcare regulations and standards — reducing liability.
- Enhanced patient engagement: Allow patients to understand and trust their care plan.
- Time efficiency: Streamline the clinical documentation process and reduce errors.
AI Scribes: The future of clinical summaries?
While scanning the above example, did you notice that it could quickly become long-winded?
This is the key issue — in 2022, the average time spent generating clinical documentation increased by 25% over the last 7 years.
This begs the question: Is there a solution?
Our answer to you is: Yes! AI scribes.
AI scribes are already lightening the documentation load—no more typing marathons.
What are AI scribes?
AI scribes are virtual assistants that use artificial intelligence to document patient encounters in real time. They listen to conversations between providers and patients, analyze the information, and create accurate and comprehensive clinical summaries.
Here are a few ways AI scribes can serve as an alternative or supplement to your current system:
- Real-time documentation: Capture patient encounters in real time and generate summaries that reduce the burden of manual data entry. This not only saves time but also ensures key details are not lost.
- Increased accuracy: Accurately transcribe complex medical terminology, significantly reducing transcription errors.
- Time savings: Free up valuable time that practitioners can spend with patients — or off the clock.
- Scalability: Scale on demand without compromising the quality of documentation.
Go beyond templates
Templates are a great start—but they still rely on you doing the work.
What if you could skip the typing entirely?
Freed is your AI medical scribe that listens, transcribes, and drafts your clinical notes—so you can focus on care, not clicks. Clinical summaries? Done while you talk.
Try Freed free and see how fast documentation can really be.
FAQs
Frequently asked questions from clinicians and medical practitioners.
How do you write a good clinical summary?
What is the difference between a clinical overview and a clinical summary?
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