Patient visit summary template, in plain language
A patient visit summary, often called an after-visit summary, is a plain-language handout telling the patient what was discussed, what the doctor thinks, which medicines to take and how, what they can do themselves, which warning signs need urgent care, and what happens next. Below is a patient visit summary template and a worked example.
Transcription and the draft note are usually ready within 1–3 minutes of pressing Stop; the note itself takes about 20–40 seconds.
Last updated Scripta by SyncEdge
Scripta drafts documentation of what was said in the visit; the clinician reviews, edits and signs; it does not diagnose.
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What should a patient visit summary include?
Six short sections: what we discussed, what the doctor thinks, your medicines, what you can do, when to get help urgently, and next steps. It is written to the patient as "you", in everyday words.
- What We Discussed
- The main problem and what the patient told the doctor, in simple words.
- What the Doctor Thinks
- The doctor's explanation of the likely cause, in simple words, only as the doctor said it.
- Your Medicines
- Each medicine with how much, how often and for how long, exactly as prescribed during the visit.
- What You Can Do
- The self-care advice the doctor gave.
- When to Get Help Urgently
- The warning signs the doctor said should bring the patient back straight away. If none were mentioned, the summary says this was not discussed.
- Next Steps
- The follow-up appointment, tests or referrals, as stated.
Patient summary example: after a visit for stomach pain
This is the summary Scripta drafted for the rice farmer after his first visit, from the same recording as the doctor's SOAP note. It speaks to him as "you", explains the medicines, and lists only the warning signs the doctor gave.
What We Discussed
You came in with a burning pain at the top of your stomach for 3 days. It is worse when your stomach is empty and a little better after eating. You vomited twice yesterday, with no blood, and your stools have not been black. For your back pain from farm work, you have been taking mixed pills from the village shop for a week, and ibuprofen when the pain is bad.
What the Doctor Thinks
The doctor thinks your stomach lining is inflamed (gastritis), or you may have a stomach ulcer. This is likely caused by the mixed pills and the painkillers you have been taking.
Your Medicines
- Omeprazole 20 mg: once a day before breakfast, for 4 weeks.
- Paracetamol 500 mg: 1 tablet every 6 hours, only when your back hurts.
- Stop the mixed pills and ibuprofen now.
What You Can Do
- Stop drinking alcohol.
- For back pain, take paracetamol instead of the mixed pills or ibuprofen.
When to Get Help Urgently
Go to the hospital straight away if you:
- vomit blood
- pass black stools
- have stomach pain that gets much worse
Next Steps
See the doctor again in 2 weeks.
Please verify (shown to the clinician, not part of the note)
- Allergy history is left out of this summary: the patient cannot name the medicine that caused an itchy rash.
- The next visit was given as "in 2 weeks", with no date.
How do you explain medicines and warning signs clearly?
One medicine per line, with what it is, how much, when and for how long. Warning signs as short things the patient can notice, with what to do. Avoid jargon, or explain it in brackets.
- "Omeprazole 20 mg: once a day before breakfast, for 4 weeks" is clearer than "omeprazole 20 mg OD ac".
- Say what to stop as clearly as what to start.
- Write warning signs as actions: "Go to the hospital straight away if you vomit blood."
- Give a date rather than an interval where you can: "on 12 October" rather than "in two weeks".
Can the summary be in Thai or English for the patient?
Yes. Choose the note language the patient reads best, whatever language the visit was held in. A Thai-speaking patient gets plain Thai; a visitor from abroad can get the same summary in English.
The Thai summary uses everyday Thai and gives each drug name in both scripts, so the patient can match it to the packet.
Should patients be told AI helped write it?
Yes. Add a line such as "Prepared with AI assistance and reviewed by Dr ____" before you hand it over. Patients should know how the document was made, and that a doctor checked it.
The template below ends with that line. Never hand over a summary you have not reviewed: it goes straight to the patient, with no other clinician reading it after you.
What should I say so the summary is right for the patient?
Explain things to the patient the way you would want them written down. The summary reuses your own explanation, so a clear sentence to the patient becomes a clear line on the page.
- Explain the likely cause in plain words: "Your stomach lining is inflamed, probably from the pills."
- Give each medicine with dose, timing and duration, and say what to stop.
- Say the warning signs out loud. If you do not, the summary says they were not discussed.
- Give the next appointment, ideally with a date.
- Choose the patient's language as the note language.
How does Scripta write a patient summary?
It drafts the six sections from the visit in plain language, addressed to the patient as "you". It includes only what the doctor said, copies doses as prescribed, and leaves out what it could not confirm, telling you why in the Please verify list.
- Headings are written in the note language, unlike SOAP, H&P and progress notes.
- Warning signs are never invented: if none were given, the section says so.
- In the example, the allergy history was left out because the patient could not name the drug, and a flag says so.
- Scripta sends nothing to patients: you review the summary, then print it or share it through your clinic's usual channel.
- Patients can speak Thai, Thai mixed with English, or Isan, Northern or Southern Thai: Scripta accepts the speech, writes the note in standard Thai (or English, if you choose), and flags any word it isn't sure of for you to check.
Copy the patient summary template
Six plain-language headings and an AI disclosure line. Fill it in for the patient, or let Scripta draft it from the visit.
What We Discussed Why you came in, and what you told the doctor: What the Doctor Thinks The likely cause, in plain words: Your Medicines Medicine name (what it is for): how much, how often, for how long Medicines to stop: What You Can Do Things that help at home: When to Get Help Urgently Go to the hospital straight away if you: Next Steps Your next appointment (date), tests or referrals: Prepared with AI assistance and reviewed by Dr ____ on ____.
Frequently asked questions
What is the difference between a patient summary and a discharge summary?
A patient visit summary is written for the patient, in plain words, after an outpatient visit: what was discussed, the medicines and when to come back. A discharge summary is written for other clinicians when a patient leaves hospital, in clinical language. Scripta's patient summary is the first kind.
Which warning signs should go on the summary?
Only the ones the doctor actually told the patient. If no warning signs were discussed, Scripta says so under When to Get Help Urgently instead of inventing a list, which is your cue to add them before handing it over.
Can the patient get a printed copy?
Yes. Copy the reviewed summary into your own document or HIS and print it, or pass it on the way your clinic normally shares documents with patients. Scripta does not send anything to patients itself, so nothing reaches the patient until you have checked it and chosen to hand it over.
Can I send the summary to a patient by LINE or email?
That depends on your clinic's own data-protection policy for sending health information, because the summary contains health data. Scripta never shares medical visits by public link; you copy the reviewed text and share it through whichever channel your clinic has approved, such as a printout or its official messaging account.
Does the summary replace talking to the patient?
No. The summary records what you explained, so the patient can re-read it at home and share it with family who help with their care. Explain first, check the patient has understood, then hand over the summary as a reminder of the medicines, warning signs and next steps.
Can I write a patient summary and a SOAP note from the same visit?
Yes. One recording can have several notes: the SOAP note for your chart and a patient summary to hand over, each written from the same conversation. Each note is charged as its own AI note, 5 credits for a visit up to 10 minutes, and you review both before use.
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