Clinical template
Medical Chart Template
A medical chart is the whole record, not one visit. The skeleton below is what a family-practice or clinic chart needs before the first SOAP goes in: who the patient is, what can kill them, what they take, and how you will find the last encounter.
Blank chart skeleton
Copy this into a new EMR chart, a paper divider, or a Scribeberry custom template. Keep the Cumulative Patient Profile (CPP) on one screen. Encounter notes live underneath it, newest first.
Medical chart
IDENTIFIERS Name / preferred name / pronouns: DOB / age / sex recorded at birth: Chart / MRN: PHN / provincial health number: Address / phone / emergency contact: Preferred pharmacy / language / interpreter needed: Family physician / MRP / roster status: CPP — ALWAYS CURRENT Problem list (active / past, with year started): Surgeries / hospitalizations: Allergies / adverse reactions (drug, reaction, date, certainty): Medications (drug, dose, frequency, indication, started): Immunizations: Family history (first-degree, relevant): Social: tobacco / alcohol / substances / occupation / housing / caregiving: Advance directives / goals of care: PREVENTION / FLOW Screening due (cervical, colorectal, breast, diabetes, lipids, immunizations): Measurements trend (BP, A1c, eGFR, weight): ENCOUNTER LOG (newest first) Date / time / clinician / location / visit type: Note (SOAP, progress, phone, result): Orders / prescriptions / letters generated this visit: Signature / designation:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, billing rules, or your own clinical judgment. Review every generated note before it enters the chart.
Chart versus the note you wrote today
The chart is the file. The note is one timed entry inside it. If you treat them as the same thing, the problem list rots, allergies sit in last week's SOAP, and the next clinician opens a 40-page narrative looking for the ACE inhibitor.
| Layer | Lives here | Update when |
|---|---|---|
| Identifiers | Name, DOB, PHN, contacts, roster, pharmacy | Registration, or the moment any of it changes |
| CPP | Problems, meds, allergies, surgeries, social, directives | Every visit that changes one of those facts |
| Prevention / flowsheets | Screening, vitals trends, A1c, INR, weights | When you act on a result or complete a manoeuvre |
| Encounter notes | What happened this visit, orders, counselling | At the time of the encounter, or as a labelled late entry |
Canadian outpatient EMRs (Accuro, OSCAR, TELUS CHR, Med Access, Plexia) all separate a CPP or equivalent from the visit note. Inpatient charts add a face sheet, orders, MAR, and discharge. The rule is the same: do not bury a new warfarin start only inside today's narrative.
Keeping the CPP honest
Write allergies as drug, reaction, date, and how sure you are. 'NKDA' copied forward for a decade is how penicillin rashes disappear. If the patient now reports a rash, add it to the CPP in the same sitting as the note.
Problem lists need a start year and a status. 'Asthma' without 'childhood, inactive' or 'T2DM 2019, on metformin' forces every reader to reconstruct the story. Drop resolved problems to past. Do not leave 'query PE 2014' on the active list if CT was negative.
- Meds: drug, dose, frequency, indication. 'Patient's own meds' is not a list.
- If you stopped a drug today, stop it on the CPP and say so in Plan.
- Social facts that change management (housing, caregiving, no fixed address, interpreter) belong on the CPP, not only in one HPI.
- Goals of care and substitute decision-maker go on the CPP once, then get confirmed, not rediscovered.
Example 1 — new rostered patient
Family medicine, new patient
44-year-old woman, Saskatoon. 30-minute rostering visit. Fictional.
IDENTIFIERS Priya Nandakumar, she/her. DOB 1982-03-14. SK health number on file. Prefers English. Pharmacy: Shoppers 8th St. Emergency contact: spouse, Raj, mobile on file. Rostered to this clinic today. No prior EMR here; paper records requested from previous GP in Regina. CPP Active: iron-deficiency anemia (2022), migraine without aura (teens), mixed anxiety-depression (2020). Past: C-section 2016. No other surgeries. Allergies: ramipril — cough, 2019, certain (switched to amlodipine, later stopped). NKDA otherwise. Meds: sertraline 75 mg PO daily; sumatriptan 50 mg PO PRN (uses ~1/month); ferrous fumarate 300 mg PO daily. Immunizations: COVID and influenza 2025; tetanus 2018; HPV unknown. Family: mother T2DM; father MI age 58. Social: non-smoker, 3–4 standard drinks/week, no recreational drugs. Accountant, two children 10 and 8. Secure housing. Directives: no document on file; substitute is spouse. Discussed, not completed today. PREVENTION Cervical screen due (last 2022). Mammogram not yet indicated. Colorectal: start 50 or sooner if symptoms. Fasting glucose/A1c, lipids, ferritin, CBC ordered today. ENCOUNTER 2026-08-28 09:10 in-person, Dr. [name]. New patient intake. See SOAP this date. Records request sent. RTC 8 weeks with labs, or sooner if migraine pattern changes.
Example 2 — walk-in, thin file
Walk-in clinic
29-year-old man, Mississauga. Unrostered. 12-minute visit. Fictional.
IDENTIFIERS Jonah Clarke, he/him. DOB 1997-11-02. OHIP on file. Phone only, no email. No family physician. Lives in a basement suite, roommate is emergency contact (first name only). Prefers English. CPP (built from today's history — flag as incomplete) Active: none documented prior. Today: acute right ankle inversion injury. Past: none volunteered. No hospital card in province under this name (clerk checked). Allergies: unknown — patient says "I don't take pills." Recorded as allergies not verified, not as NKDA. Meds: none. Social: warehouse picker, steel-toed boots, cash work some weekends. Smokes 1/2 pk/day. No fixed GP. PREVENTION Not addressed beyond tetanus: last booster unknown. Offered, declined today. Documented. ENCOUNTER 2026-08-28 19:40 walk-in. Right ankle sprain, Ottawa rules negative, tensor + RICE, off work 3 days with note. Advised to roster with a family practice; list of accepting clinics printed. Chart will be a single-visit file unless he returns. Do not copy this CPP into a future rostered chart without re-confirming allergies and meds.
Example 3 — inpatient face sheet
Medicine ward admission
81-year-old man, Saint John, NB. Admitted from ED overnight. Fictional.
IDENTIFIERS Harold MacKinnon, he/him. DOB 1945-06-21. NB Medicare on file. MRN assigned. From home, daughter Fiona is SDM and emergency contact. Family physician: Dr. [name], uptown. Language: English. Hearing aids in situ. CPP / ADMISSION PROBLEM LIST 1. Community-acquired pneumonia, right lower lobe — reason for admission. 2. CKD stage 3, baseline Cr ~140 (clinic labs 2025). 3. HFpEF, last echo 2024, EF 55%, on furosemide. 4. Atrial fibrillation, on apixaban 2.5 mg BID (age/Cr). 5. Type 2 diabetes, metformin held on admission. Allergies: sulfa — rash, 1990s, certain. No penicillin allergy. Meds on admission (best-possible med history with daughter + blister pack): apixaban 2.5 mg BID, furosemide 40 mg AM, ramipril 5 mg daily, metformin 500 mg BID, atorvastatin 20 mg qhs, cholecalciferol 1000 IU daily. Code status: full code, confirmed with daughter 02:10. Goals-of-care conversation pending with MRP in AM. Social: widowed, home with homecare 2x/week. No alcohol. Ex-smoker 40 pack-years, quit 2001. ENCOUNTER LOG 2026-08-28 01:55 ED note (see ED chart). 2026-08-28 02:20 admission orders: ceftriaxone, oxygen to SpO2 ≥92%, hold metformin, hold ramipril if SBP <110, daily weights, diet diabetic. 2026-08-28 08:40 MRP admission note to follow.
Mistakes that make the next visit unsafe
- Leaving the allergy field blank and writing NKDA in the note only.
- A problem list that is a dump of every billing code from 2011.
- Meds that do not match the pharmacy profile, with no attempt at a best-possible medication history.
- Two charts for the same person after a name change or a hyphen, never merged.
- Copy-forwarding last year's social history while the patient is now unhoused.
- Unsigned encounter notes sitting in draft after you have already acted on them.
CMPA's documentation advice is blunt: the record has to show who the patient is, what you knew, and what you did. A beautiful SOAP on top of a rotten CPP still fails that test. Colleges expect you to correct the chart when a generated note is wrong. An AI draft does not change who signs.
Draft the chart pieces from the visit
Scribeberry listens to the encounter, or takes dictation, and drafts the note plus the med, allergy, and problem updates you still have to confirm. Edit, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a medical chart?
A medical chart is the longitudinal health record for one person: identifiers, problem list, allergies, medications, and dated encounter notes. A SOAP note is one visit inside that chart, not the chart itself.
What belongs on the Cumulative Patient Profile?
Active and past problems, surgeries, allergies with reactions, current medications, immunizations, relevant family history, social facts that change care, and goals of care. Update it whenever one of those facts changes, not once a year.
How do Canadian clinics structure a new-patient chart?
Registration captures identifiers and the health number. The first clinical visit builds the CPP, requests old records, and writes an intake note. Prevention and screening then sit on a flowsheet so they are not buried in narrative.
Can Scribeberry fill a medical chart template?
Yes. Pick a chart or intake template (or your own headings), record or dictate, and generate. You review identifiers, allergies, and meds before anything is pushed to the EMR. Custom templates and memories keep the headings in your voice.
Templates
