4.5. Writing Clinical Summaries
Learning Objectives
By the end of this lesson, students will be able to:
- Understand the purpose and importance of clinical summaries in healthcare communication.
- Identify and analyze the key components of an effective clinical summary.
- Write a clear and concise clinical summary using a structured format.
- Provide constructive peer feedback on clinical summaries, focusing on organization, clarity, and use of medical terminology.
- Reflect on the role of clinical summaries in enhancing patient care and teamwork in healthcare settings.
Part 1: Warm-Up
Read quickly the below paragraph about clinical summaries, and discuss the following questions in pairs or small groups:
- What is the purpose of a clinical summary?
- Who reads clinical summaries?
What is a Clinical Summary?
A clinical summary is a short written record that explains a patient’s important health information. It usually includes the patient’s basic information, medical history, current health problems, treatment plan, and instructions for follow-up care. Clinical summaries help doctors, nurses, and medical assistants communicate clearly about a patient’s needs. They also help patients remember what happened during their visit and what they need to do next. Writing a clear clinical summary is an important skill for anyone working in healthcare.
Part 2: Understanding Clinical Summary Components
Review the following key components of a clinical summary. Work in pairs, and in turn explain the reason why each component is important:
- Patient Demographics: Name, age, gender, etc.
Importance: ____________________________________________ - Medical History: Summary of past and current health conditions.
Importance: ____________________________________________ - Current Health Issues: The main reason for the visit or concern.
Importance: ____________________________________________ - Treatment Plan: Actions taken or prescribed during the visit.
Importance: ____________________________________________ - Recommendations for Follow-Up Care: Next steps for the patient.
Importance: ____________________________________________
Discuss your answers as a class.
Part 3: Effective vs Ineffective Clinical Summaries
In pairs, read the two sample clinical summaries above.
- Use the table below to compare the two summaries:
| Criteria | Effective Summary | Ineffective Summary |
| Clarity and Conciseness | _______________________________ | ___________________________________ |
| Use of Medical Terminology | _______________________________ | ___________________________________ |
|---|---|---|
| Structure and Organization | _______________________________ | _ |
Effective summary
Patient Name: Sarah Johnson
Age: 35
Gender: Female
Date of Visit: April 28, 2025
Medical History:
- Asthma diagnosed at age 12, managed with an inhaler.
- No hospitalizations related to asthma.
- Allergies: Pollen and dust.
Current Health Issue:
- Patient presents with shortness of breath and a persistent cough for the past week, worsened by physical activity.
Treatment Plan:
- Prescribed a new inhaler (Albuterol) to be used as needed.
- Instructed on proper inhaler technique.
- Advised to avoid known triggers, including dust and pollen.
Recommendations for Follow-Up Care:
- Schedule a follow-up appointment in two weeks to evaluate the effectiveness of the new inhaler and monitor symptoms.
- Patient to contact the clinic if symptoms worsen or if there are any side effects from the medication.
Ineffective summary
Patient Name: S. Johnson
Age: 35
Date of Visit: 4/28/25
History:
- Has asthma.
- Allergies.
Current Issue:
- Coughing and breathing problems.
Plan:
- New inhaler.
- Avoid triggers.
Follow-Up:
- Come back later.
- What makes the effective summary clear and easy to understand?
- What improvements could be made to the ineffective summary?
Part 4: Writing a Clinical Summary
Read the hypothetical patient scenario below and write a clinical summary using the provided clinical summary template.
Patient Scenario:
Maria Lopez, a 45-year-old female, visited the clinic today complaining of severe lower back pain that started three days ago after lifting heavy boxes at work. She has a history of mild arthritis but no previous serious back injuries. During the exam, she rated her pain as 8 out of 10. The provider diagnosed her with a muscle strain and prescribed ibuprofen 400 mg to be taken three times a day with food. Maria was advised to rest, apply ice to her back for 20 minutes several times a day, and avoid heavy lifting for the next two weeks. She was also referred to physical therapy and scheduled for a follow-up visit in two weeks to check her progress.
Clinical Summary Template
| Key Component | Your Summary |
|---|---|
| Patient Demographics | _________________________________________________ |
| Medical History | _________________________________________________ |
| Current Health Issue | _________________________________________________ |
| Treatment Plan | _________________________________________________ |
| Recommendations for Follow-Up Care | _________________________________________________ |
Part 5: Peer Review & Feedback
Exchange your clinical summary with a partner.
Use the checklist below to review your partner’s summary. Provide constructive feedback:
Peer Review Checklist:
| Criteria | Yes/No | Comments |
|---|---|---|
| Is the summary clear and concise? | ||
| Does it include all key components? | ||
| Is the medical terminology used correctly? | ||
| Is the structure logical and organized? |
Write 1–2 sentences summarizing your feedback:
Part 6: Wrap-up & Reflection
Reflect on today’s lesson and answer the following questions:
- What did you learn about writing clinical summaries?
- What was the most challenging part of writing or reviewing a clinical summary?
- How can you apply these skills in your future role as a healthcare professional?
- Share one takeaway from the lesson with the class. Write down an idea shared by another student that you found helpful:
