Medical Chart Template: Streamline Documentation with Docscrib’s AI Scribe

Updated on: July 2, 2025

Medical documentation is vital for patient care, clinical communication, legal compliance, and reimbursement. But for most clinicians, charting is time-consuming, repetitive, and often incomplete under pressure.

A well-designed medical chart template can save time, reduce documentation errors, and ensure consistent, high-quality records — whether you’re in primary care, emergency medicine, pediatrics, or specialty practice.

Even better? When templates are powered by AI.

With Docscrib, you get the best of both worlds — customizable chart templates plus a real-time AI medical scribe that generates complete clinical notes while you focus on patients.

🧠 Use proven templates. Add the power of AI. Reclaim your time.

What Is a Medical Chart Template?

A medical chart template is a structured format that clinicians use to document a patient’s visit. Templates standardize the way key clinical information is captured, including:

• Chief complaint

• History of present illness (HPI)

• Review of systems (ROS)

• Physical examination

• Assessment & Plan

• Procedures

• Follow-up instructions

Using structured templates ensures:

• ✅ Faster note creation

• ✅ Compliance with billing and coding

• ✅ Consistent terminology and format

• ✅ Better EHR integration

• ✅ Reduced burnout for clinicians

Free Medical Chart Template (SOAP Format)

Here’s a downloadable template you can adapt across care settings:

📝 Medical Chart Template (SOAP)

Patient Name: ____________________
Date of Visit: ____________________
Provider: _________________________
Visit Type: ☐ New ☐ Follow-Up ☐ Telehealth

S – Subjective
Chief Complaint: ______________________________________
History of Present Illness (HPI):

Past Medical History: ___________________________________
Allergies: ____________________ Medications: _______________
Social History: ________________________________________

O – Objective
Vitals: BP: ___ / ___ HR: ___ Temp: ___ SpO₂: ___ RR: ___
General Appearance: _______________________________
HEENT: __________________________________________
CV/Resp: _________________________________________
Abdomen: ________________________________________
Neuro: ___________________________________________
Other: ____________________________________________

A – Assessment

P – Plan

• Labs/Imaging Ordered: ________________________

• Medications Prescribed: ______________________

• Procedures Done: ____________________________

• Education Provided: __________________________

• Follow-Up: _________________________________

📥 Download this free template at Docscrib.com

Other Common Charting Templates

Depending on your specialty or care setting, you might use:

✅ H&P Template (History & Physical)

Common for inpatient admissions and consults.

✅ SOAP Note Template

Great for outpatient clinics and primary care follow-ups.

✅ ER Visit Note Template

Focused on acute triage, diagnostics, and rapid disposition.

✅ Progress Note Template

Used in inpatient rounds for daily updates.

✅ Discharge Summary Template

Summarizes hospital course, follow-up plan, and final diagnoses.

Why Templates Alone Aren’t Enough — Enter Docscrib’s AI Medical Scribe

While templates reduce friction, they still require manual typing and cognitive effort — especially after long clinic days. That’s where Docscrib’s AI medical scribe changes the game.

🔹 How It Works:

1. You speak naturally during your patient visit

2. Docscrib listens securely and interprets your conversation

3. A complete, structured chart note is generated in real-time

4. You review and approve before submission to EHR

🩺 “Docscrib saved me 10+ hours a week. I now leave work on time with every chart closed.”
— Family Physician, Florida

Docscrib vs. Manual Templates

Ideal for Every Clinical Setting

Whether you’re in private practice or hospital-based care, Docscrib supports:

• 🩺 Primary Care & Internal Medicine

• 🧠 Psychiatry & Behavioral Health

• 🦴 Orthopedics

• 🦷 Dentistry

• 🧒 Pediatrics

• 🏥 Emergency Medicine

• 🧬 Oncology & Gastroenterology

• 👩‍⚕️ Nursing Documentation

FAQs About Medical Chart Templates & AI Scribes

Is Docscrib HIPAA-compliant?

Absolutely. Docscrib is HIPAA-compliant, SOC 2 certified, and built with enterprise-grade encryption.

Can I still use my existing templates with Docscrib?

Yes. You can upload or adapt your templates, and Docscrib will format your AI-generated notes to match.

Do I still have control over the final note?

100%. You review and approve every note before it’s submitted to the EHR.

Final Thoughts: Templates + AI = Smarter Documentation

Medical chart templates are essential for improving chart quality and saving time. But paired with Docscrib’s AI medical scribe, you unlock the next level of clinical efficiency.

With Docscrib, clinicians can:

• Finish charts during the encounter

• Maintain structured, consistent documentation

• Eliminate after-hours admin time

• Improve billing accuracy and compliance

• Deliver better patient care

👉 Try Docscrib — AI-Powered Medical Charting That Works for You

👉 Download Templates & Learn More at Docscrib.com