The Two-Layer Note System: Clinical Note + Patient-Friendly Summary (2026 Best Practice)

Every clinician faces the same documentation dilemma: write notes detailed enough for clinical accuracy and legal defensibility, or write notes simple enough for patients to actually understand. In 2026, with open notes mandates and rising patient expectations, you can no longer choose one over the other.

The two-layer note system resolves this tension by producing two outputs from every encounter: a full clinical note (Layer 1) for the medical record, and a patient-friendly summary (Layer 2) that the patient takes home. Same session, two documents, two audiences—each getting exactly what they need.

Why the Two-Layer Approach Is Now Essential

The Open Notes Reality

Since April 2021, the 21st Century Cures Act has required clinicians to share clinical notes with patients electronically. As of 2022, this extends to virtually the entire designated record set. Patients now read your progress notes, consultation summaries, and assessments—often without context.

Research published in JMIR Medical Education (2025) found that some patients feel judged or stigmatized by words and phrases in their records. A study in NEJM AI demonstrated that most patients—especially those with limited health literacy—struggle to understand and act on standard clinical notes.

The result: patients have access but not comprehension. That gap creates confusion, erodes trust, and undermines treatment adherence.

The Documentation Burden

Clinicians are already drowning in paperwork. Studies consistently show that documentation is a leading driver of burnout. Adding a second patient-facing document sounds like more work—but with the right structure and tools, the patient summary is derived from the clinical note, not created from scratch.

The Comprehension Dividend

When patients receive written summaries in plain language, recall improves from 14% to over 85%, according to research on patient memory (Kessels, 2003). The two-layer system doesn't just satisfy a regulatory requirement—it transforms patient outcomes by giving people information they can actually use.

The Two-Layer Framework Explained

Layer 1: The Clinical Note

This is your standard clinical documentation—SOAP format, ICD codes, clinical reasoning, objective measurements. It serves the medical record, insurance requirements, legal protection, and care continuity.

Audience: Other clinicians, auditors, insurers, legal record.

Language: Technical, precise, and complete. Abbreviations, clinical terminology, and structured assessments are appropriate here.

Key requirements:

• Meets specialty-specific documentation standards
• Supports medical decision-making and billing
• Provides legal defensibility
• Enables continuity of care across providers

Layer 2: The Patient-Friendly Summary

This is the document your patient takes home—physically or digitally. It translates the clinical note into language the patient can understand and act on.

Audience: The patient and their support network (family, caregivers).

Language: Plain, respectful, jargon-free. Written at or below a 6th-grade reading level when possible.

Key requirements:

• Explains what happened during the session
• Clarifies what was found or assessed
• States what the patient should do next
• Identifies warning signs or reasons to call
• Confirms the next appointment and goals

Reusable Template: Layer 1 (Clinical Note)

The clinical note follows your existing SOAP or specialty format. Here is a universal structure that works across disciplines:

CLINICAL NOTE — [SPECIALTY]

Date: [Date]
Session #: [Number]
Duration: [Minutes]
Provider: [Name, Credentials]

SUBJECTIVE
[Patient-reported symptoms, concerns, and changes since last visit]

OBJECTIVE
[Clinical observations, measurements, test results, examination findings]

ASSESSMENT
[Clinical interpretation, diagnostic impressions, progress toward goals]

PLAN
[Interventions performed, treatment modifications, referrals, follow-up schedule]

ICD-10: [Code(s)]
CPT: [Code(s)]
Provider Signature: _________________ Date: _________

This is your standard documentation—no changes needed if your current format already meets clinical standards.

Reusable Template: Layer 2 (Patient-Friendly Summary)

This is the document that transforms your practice. Use this template as a starting point and adapt the language to your specialty:

YOUR SESSION SUMMARY

Date: [Date]
Your provider: [Name]

WHAT WE TALKED ABOUT TODAY
[2-3 plain-language sentences summarizing the session focus.
Example: "Today we focused on the anxiety you've been feeling at
work and practiced a new breathing technique to help you manage it."]

WHAT WE FOUND
[Key findings in everyday language, avoiding jargon.
Example: "Your shoulder movement has improved since last time.
You can now lift your arm about 20 degrees higher than two weeks ago."]

WHAT YOU SHOULD DO BEFORE OUR NEXT VISIT
- [Specific action item in plain language]
- [Specific action item with frequency if applicable]
- [Any lifestyle recommendations]

THINGS TO WATCH FOR
[Warning signs that should prompt the patient to call or seek care.
Example: "If your pain increases sharply or you notice new numbness
in your fingers, please call the office right away."]

YOUR NEXT APPOINTMENT
Date: [Date/Time]
What we'll focus on: [Brief preview]

QUESTIONS?
Contact us at [phone/email] if anything is unclear.

Key Principles for Layer 2

1. Use "we" and "you" language. "We discussed your sleep habits" feels collaborative. "Patient reports insomnia" feels clinical.
2. Replace jargon with explanations. Not "ROM improved 20°" but "You can move your shoulder about 20 degrees further than last time."
3. Limit to one page. Longer summaries overwhelm patients. Prioritize what matters most for their next steps.
4. Include action items as a checklist. Patients are more likely to follow through when tasks are listed clearly.
5. Write respectfully. Avoid subjective judgments about appearance, compliance, or behavior. Use person-first language throughout.

Specialty Examples

Therapy / Mental Health

Layer 1 (Clinical Note excerpt):

S: Pt reports increased anxiety (GAD-7: 14, up from 11). Identifies
workplace conflict as primary stressor. Sleep disrupted—reports 4-5
hrs/night with initial insomnia. Denies SI/HI. Homework (thought
record) completed 3/7 days.

O: Affect anxious, speech pressured. Cooperative and engaged.
Oriented x4. Insight fair, judgment intact.

A: GAD with exacerbation secondary to occupational stressor.
Partial compliance with CBT homework. Therapeutic alliance intact.

P: Introduced diaphragmatic breathing + progressive muscle
relaxation. Assigned daily thought record with modified format
(simplified columns). F/U 1 week.

Layer 2 (Patient Summary):

YOUR SESSION SUMMARY

WHAT WE TALKED ABOUT TODAY
Today we focused on the anxiety you've been experiencing around
your work situation. Your anxiety score went up a bit since last
time (from 11 to 14 out of 21), which makes sense given the
stress you've described.

WHAT WE WORKED ON
We practiced two new relaxation techniques:
1. Deep belly breathing — slow inhale for 4 counts, hold for 4,
   exhale for 6
2. Progressive muscle relaxation — tensing and releasing each
   muscle group for 5-10 seconds

WHAT YOU SHOULD DO THIS WEEK
- Practice the belly breathing exercise twice a day (morning and
  before bed), even on days you feel calm
- Continue filling out your thought record — we simplified the
  format so it should feel easier
- Try the muscle relaxation exercise when you notice tension
  building at work

THINGS TO WATCH FOR
If you notice your anxiety becoming so intense that you can't
get through a work day, or if you have thoughts of harming
yourself, please call us immediately or contact the crisis
line at 988.

YOUR NEXT APPOINTMENT
[Date] — We'll check in on how the relaxation techniques are
working and continue building your toolkit for managing work stress.

Nutrition / Dietetics

Layer 1 (Clinical Note excerpt):

S: Pt returns for f/u. Reports improved adherence to Mediterranean
dietary pattern. Estimates 5 servings fruits/vegetables daily (up
from 2). Reports persistent evening snacking (high-sugar items).
Denies GI symptoms. Physical activity: walking 20 min x 3/week.

O: Wt: 87.2 kg (prev: 89.1 kg, -1.9 kg/4 weeks). BMI: 29.4.
WC: 98 cm (prev: 100 cm). BP: 128/82. Fasting glucose: 5.8
mmol/L (prev: 6.2).

A: Overweight with pre-diabetes. Positive trend in weight, WC,
and fasting glucose. Evening snacking pattern identified as
primary barrier to further progress.

P: Maintain current dietary pattern. Introduce structured evening
snack (protein + fiber combination) to replace high-sugar items.
Goal: reduce fasting glucose to <5.6 mmol/L. F/U 4 weeks with
repeat labs.

Layer 2 (Patient Summary):

YOUR SESSION SUMMARY

WHAT WE TALKED ABOUT TODAY
Great progress this month! We reviewed your eating habits and
measurements to see how the changes you've been making are working.

WHAT WE FOUND
- You lost 1.9 kg (about 4 lbs) since last visit — well done
- Your waist measurement went down by 2 cm
- Your blood sugar improved (from 6.2 to 5.8) — moving in the
  right direction
- You're eating more fruits and vegetables, which is making
  a real difference

WHAT YOU SHOULD DO BEFORE OUR NEXT VISIT
- Keep up the Mediterranean-style eating that's working well
- For evening snacking: swap the sugary snacks for a combination
  of protein + fiber. Some ideas:
    * Greek yogurt with berries
    * Apple slices with a tablespoon of peanut butter
    * A small handful of nuts with a piece of fruit
- Continue your walking routine (3 times a week, 20 minutes)
- You'll need a fasting blood test before our next visit — the
  lab form is attached

THINGS TO WATCH FOR
If you experience unusual thirst, frequent urination, or blurred
vision, contact your doctor as these can be signs of elevated
blood sugar.

YOUR NEXT APPOINTMENT
[Date] — We'll review your new lab results and see how the
evening snack swap is going. Our goal is to get your fasting
blood sugar below 5.6.

Dental

Layer 1 (Clinical Note excerpt):

S: Pt presents for routine prophylaxis. Reports intermittent
sensitivity LR quadrant with cold stimulus, onset ~2 weeks.
Denies spontaneous pain. Brushing 2x/day, flossing irregular.
No changes to medications.

O: Exam: Moderate calculus LR quadrant. Gingival inflammation
#18-20 (BOP+). Probing depths 2-4mm, isolated 5mm #19 DL.
Radiograph: incipient interproximal caries #19 MO. No periapical
pathology. Sensitivity test #19 positive, within normal response.

A: Localized chronic gingivitis LR quadrant. Incipient caries
#19 MO. Dentinal hypersensitivity #19.

P: Prophylaxis completed with ultrasonic + hand scaling. Fluoride
varnish applied. Schedule #19 MO composite restoration. OHI
reinforced: flossing technique + interproximal brush demo. Rx
sensitivity toothpaste. Recall 6 months.

Layer 2 (Patient Summary):

YOUR VISIT SUMMARY

WHAT WE DID TODAY
We completed your cleaning today. We spent extra time on the
lower right area where some buildup had accumulated, and we
applied a protective fluoride treatment.

WHAT WE FOUND
- Lower right area: Your gums are a bit inflamed because plaque
  has been building up between the teeth. This is early-stage
  gum irritation — it's very reversible with good flossing
- Tooth #19 (lower right molar): We found a very small cavity
  starting between two teeth. It's early, so a simple filling
  will take care of it
- The cold sensitivity you mentioned is coming from that same
  tooth — it's not a sign of anything serious

WHAT YOU SHOULD DO
- Start using the sensitivity toothpaste we recommended — brush
  with it normally and also rub a small amount directly on the
  sensitive tooth at night
- Floss daily, especially in the lower right area. Use the
  technique we showed you today (C-shape around each tooth)
- Consider the small interproximal brushes for the gaps between
  your back teeth — they're very effective

WHAT'S NEXT
- We need to schedule a short appointment to fill the small
  cavity on your lower right molar. The earlier we do this,
  the simpler the procedure
- Your next routine cleaning will be in 6 months

WHEN TO CALL US
If the sensitivity gets worse, lasts more than a few seconds
after eating/drinking, or you notice any spontaneous pain,
give us a call.

How to Build a Two-Layer Workflow

Step 1: Start with Your Clinical Note

Write your Layer 1 documentation as you normally would. Don't change your clinical process or compromise on detail.

Step 2: Extract the Patient Essentials

From your completed clinical note, identify:

• The 2-3 most important findings
• Action items the patient needs to follow
• Any warning signs relevant to their condition
• The next appointment and its purpose

Step 3: Translate to Plain Language

Rewrite the extracted information using these rules:

• Replace every medical term with an everyday equivalent
• Use short sentences (under 20 words when possible)
• Write in second person ("you" and "your")
• Structure information as bullet points or numbered lists
• Keep the total summary to one page

Step 4: Deliver Promptly

Provide the patient summary within 24 hours of the session—ideally before the patient leaves. Digital delivery (email, patient portal) ensures they have it when they need it.

Common Pitfalls to Avoid

Duplicating Effort

The two-layer system should not mean writing everything twice. Layer 2 is a translation and distillation of Layer 1, not a parallel document. If you find yourself spending more than 3-5 minutes on the patient summary, your workflow needs optimization.

Watering Down Clinical Notes

Some clinicians, aware that patients will read their notes, start self-censoring the clinical record. This is dangerous. Your clinical note must remain complete and honest. The patient summary is where you adapt the message—not the clinical note.

Ignoring Health Literacy

Nearly 36% of U.S. adults have limited health literacy. Writing a patient summary at a college reading level defeats the purpose. Use tools like the Flesch-Kincaid readability test to check your summaries, and aim for a 6th-grade reading level or below.

Forgetting the Action Items

A summary that explains what happened but doesn't tell the patient what to do next is incomplete. Every patient summary should include specific, actionable steps the patient can follow.

How AI Tools Are Changing the Equation

The biggest objection to two-layer documentation has always been time. Writing one set of notes is already a burden—writing two seems impossible.

AI-powered clinical documentation tools have eliminated this barrier. Modern solutions can:

• Generate Layer 1 from session recordings or real-time transcription
• Automatically produce Layer 2 by translating clinical findings into plain language
• Maintain consistent formatting across all sessions and providers
• Adapt reading level to match patient needs

This means the two-layer system no longer requires extra clinician time. The AI handles the translation while you maintain oversight and clinical judgment.

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Want to implement the two-layer note system without adding to your workload? Dya automatically generates both clinical notes and patient-friendly summaries from your sessions—so every patient leaves with a document they can actually understand.

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References

Kessels, R. P. C. (2003). Patients' memory for medical information. Journal of the Royal Society of Medicine, 96(5), 219-222. https://pmc.ncbi.nlm.nih.gov/articles/PMC539473/

OpenNotes. (2021). U.S. Federal Rule Mandates Open Notes — 21st Century Cures Act. https://www.opennotes.org/onc-federal-rule/

Nath, B. et al. (2025). Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study. JMIR Medical Education, 2025(1), e59301. https://mededu.jmir.org/2025/1/e59301

Zaretsky, J. et al. (2024). A Cross-Sectional Study of GPT-4–Based Plain Language Translation of Clinical Notes to Improve Patient Comprehension. NEJM AI. https://ai.nejm.org/doi/abs/10.1056/AIoa2400402

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• Session Report Template for Therapists: Structure, Examples & Common Mistakes
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• Patient Care Plan PDF & Adherence Checklist: Improve Treatment Follow-Through
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