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Medical Documentation Practice

Clinical notes, discharge summaries, referral letters — the documentation that healthcare workers type every single shift.

Patient Intake Note

A standard intake note with presenting complaint, vitals, and relevant history. Common clinical abbreviations included.

Part 1 of 1
CC: 52-year-old male presents with 3-day history of productive cough, low-grade fever (38.1 C), and mild dyspnea on exertion. PMH: hypertension, type 2 diabetes mellitus. Current meds: metformin 1000 mg BID, lisinopril 10 mg daily. No known drug allergies.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 30 WPM
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⏱️ Start typing...

Discharge Summary

A brief discharge summary with diagnosis, treatment, and follow-up instructions. Standard hospital documentation format.

Part 1 of 1
Patient was admitted for acute pyelonephritis with urosepsis. Blood cultures grew E. coli, sensitive to ceftriaxone. IV antibiotics initiated; patient transitioned to oral ciprofloxacin 500 mg BID on day 3. Discharged in stable condition. Follow-up with primary care in 7-10 days for repeat urinalysis.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 28 WPM
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⏱️ Start typing...

Prescription Narrative

A written prescription with medication name, dose, route, and frequency. Precision matters here.

Part 1 of 1
Amoxicillin-clavulanate 875 mg / 125 mg orally twice daily for 10 days. Take with food to reduce GI upset. Dispense 20 tablets. One refill. Patient counseled on completing full course and to notify clinic if rash or diarrhea develops.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 30 WPM
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⏱️ Start typing...

Lab Results Narrative

A narrative summary of lab findings. You will type a lot of numbers, units, and reference ranges.

Part 1 of 1
CBC: WBC 11.4 x10/uL (elevated), Hgb 13.2 g/dL, Hct 39.8%, platelets 224 x10/uL. CMP: sodium 138 mEq/L, potassium 4.1 mEq/L, creatinine 0.9 mg/dL, glucose 142 mg/dL (elevated). HbA1c 7.8%. Lipid panel: LDL 118 mg/dL, HDL 44 mg/dL, triglycerides 187 mg/dL.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 25 WPM
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⏱️ Start typing...

Referral Letter

A referral to a specialist with reason, relevant history, and urgency level. Professional letter format.

Part 1 of 1
Dear Dr. Patel, I am referring Ms. Karen Olsen, DOB 04/12/1968, for gastroenterology evaluation of persistent GERD symptoms unresponsive to twice-daily PPI therapy for 8 weeks. She has had no hematemesis, melena, or unintentional weight loss. I would appreciate your assessment and consideration for upper endoscopy.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 28 WPM
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⏱️ Start typing...

Medical History

A past medical and surgical history entry. The slash and abbreviation conventions are typical of real charts.

Part 1 of 1
PMH: coronary artery disease (stent placement 2019), chronic obstructive pulmonary disease (GOLD Stage II), gastroesophageal reflux disease. PSH: appendectomy (1998), right total knee arthroplasty (2021). Family history: father with MI at age 58, mother with breast cancer. Social history: former smoker, 20 pack-year history, quit 2015.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 28 WPM
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⏱️ Start typing...

Clinical Observation Note

A SOAP-format observation note. The structured format is used across all specialties so it is worth practicing.

Part 1 of 1
S: Patient reports improved pain control, 3/10 from 7/10 yesterday. Tolerating oral fluids without nausea. O: Afebrile, HR 78, BP 122/74, SpO2 97% on room air. Abdomen soft, mild tenderness at RLQ incision site, no rebound. WBC trending down to 8.2. A/P: Post-op day 2 appendectomy, recovering well. Continue current regimen, advance diet as tolerated.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 28 WPM
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⏱️ Start typing...

Procedure Note

A brief procedure note for a minor bedside procedure. Consent, technique, and outcome are the three required pieces.

Part 1 of 1
Procedure: Lumbar puncture. Indication: rule out meningitis. Consent obtained. Patient positioned in left lateral decubitus. L3-L4 interspace identified. Skin cleansed with chlorhexidine. 22-gauge spinal needle inserted without difficulty. Opening pressure 16 cm H2O. CSF clear and colorless. Four tubes collected, sent to lab. No immediate complications. Patient tolerated procedure well.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 25 WPM
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⏱️ Start typing...

Radiology Report

An X-ray report with technique, findings, and impression. Radiologists have a very consistent report structure.

Part 1 of 1
Examination: PA and lateral chest radiograph. Clinical indication: cough, rule out pneumonia. Technique: Standard PA and lateral projections. Findings: Lungs are clear bilaterally with no focal consolidation, pleural effusion, or pneumothorax. Cardiac silhouette normal in size. Mediastinum unremarkable. Bony thorax intact. Impression: No acute cardiopulmonary abnormality.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 28 WPM
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⏱️ Start typing...

Nursing Assessment

A nursing shift assessment note. Orientation status, pain, and system-by-system findings are the standard components.

Part 1 of 1
Patient alert and oriented x3, cooperative. Pain 4/10, describes as achy in bilateral lower extremities. Skin warm and dry, no new lesions. Peripheral IV site right antecubital, patent, no signs of infiltration. Bowel sounds present x4 quadrants. Voiding adequate amounts of clear yellow urine. Ambulated in hallway with RN assistance x2 this shift without incident.
WPM 0
Accuracy 100%
Progress 0%
Streak 0 🔥
Speed Target: 30 WPM
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⏱️ Start typing...
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