The Chart Room
Clinical documentation, written for clinicians.
Templates, smart phrases, and MDM guides for PAs, NPs, physicians, residents, and students - from urgent care to the ED.
Latest from The Chart Room
- URI Documentation Template: Viral URI is one of the highest-volume diagnoses in urgent care. Here's how to document it efficiently, demonstrate appropriate MDM, and practice antibiotic stewardship - all in one visit.
- Chest Pain Documentation Example: Chest pain demands documentation that reflects your full clinical reasoning - not just your findings. Here's a model note that captures the complexity, supports high-level MDM, and holds up to retrospective review.
- Sports Physical Documentation Template: PPE season hits all at once. A clean, thorough sports physical note protects the patient, satisfies school requirements, and takes less time than you think when you have the right template.