Clinical document templates
Free clinical document templates written and shared by clinicians on Rhazes, from SOAP notes and discharge summaries to referral letters.
621 shared by clinicians · Page 1 of 13
- Emergency Medicine Assessment NoteStructured format to capture emergency patient assessment
Emergency Medicine Specialist
- Continuation Sheet
Emergency Medicine Specialist
- HandoverHandover patient between clinicians, nurses and paramedics
Emergency Medicine Specialist
- ED NotesClinical ED notes
Emergency Medicine
- Senior Review post-Junior discussionUsed when a junior doctor presents a case to a senior, who then records the discussion and formulates a management plan for the patient.
Emergency Medicine Specialist
- ED Notes 1FRCEM standards
Emergency Medicine
- Nursing Handover SBAR TemplateA structured SBAR handover template for nursing staff shift transitions.
Emergency Medicine
- Full Eating Disorder AssessmentA comprehensive template for documenting an eating disorder assessment, including presenting concerns, physical measurements, weight and eating history, mental state, risk, diagnosis, and treatment planning. It is designed for detailed clinical documentation based only on explicitly provided information.
Psychiatrist
- Physiotherapy Evaluation NoteA structured template for documenting physiotherapy evaluations, including the presenting concern, condition history, medical history, objective findings, assessment, diagnosis, goals, rehabilitation potential, interventions, and patient education. It supports comprehensive treatment planning and follow-up documentation.
Physiotherapist
- New Patient NoteThis template structures a comprehensive initial periodontal assessment for a new patient. It covers presenting concerns, dental and medical history, extraoral and intraoral findings, investigations, diagnoses, prognosis, treatment recommendations, follow-up, and financial discussions.
Periodontist
- Detailed Lactation ConsultationA comprehensive SOAP-style template for lactation consultants documenting breastfeeding consultations. It covers subjective concerns, maternal and infant assessments, milk transfer, pumping, oral and suck findings, feeding observations, clinical assessment, and follow-up planning.
Lactation Consultant
- Prosthodontic Consultation Update LetterA structured letter template for updating the referring clinician after a consultation. It covers the referral context, presenting concerns, relevant history, medications, findings, management, follow-up, and clinician sign-off.
Prosthodontist
- EMDR Session NoteA structured template for documenting EMDR therapy sessions, including client-reported concerns, trauma-related psychological and physical experiences, clinical assessment findings, interventions, treatment response, and follow-up planning.
Psychiatrist
- Dietitian Doctor LetterA structured template for dietitians to document patient consultations, covering the referral reason, relevant history, dietary assessment, anthropometry, impression, recommendations, and follow-up. It supports concise, comprehensive communication with the referring doctor using only explicitly provided information.
Dietitian
- Chiropractor AdjustmentA structured template for documenting chiropractic visits, including subjective history, objective examination findings, assessment, adjustments, additional therapies, and follow-up care.
Chiropractor
- Dietitian Nutrition Assessment and Care PlanA structured template for recording dietary intake, nutrition assessment, interventions, goals, monitoring, and follow-up. It supports organized documentation of nutrition concerns, education, referrals, and care planning.
Dietitian
- Functional Assessment InterviewA structured interview template for documenting a person’s background, health, communication and daily living skills, social functioning, and behaviours of concern. It also captures antecedents, consequences, preferences, and contextual factors that may support functional assessment and individualized behaviour planning.
Behaviour Therapist
- Child and Adolescent Psychiatric AssessmentA structured template for an initial child and adolescent psychiatric evaluation, incorporating information from the young person and caregivers. It covers presenting concerns, psychiatric and medical history, development, psychosocial context, examination, formulation, diagnosis, treatment, and safety planning.
Child and Adolescent Psychiatrist
- Palliative Care Consult NoteA reusable template for documenting a comprehensive palliative care consultation. It covers medication status, clinical presentation, examination findings, symptom management, mobility, family support, education, end-of-life planning, follow-up, and death certificate arrangements.
Palliative Care Physician
- Gastroenterology Follow-upA reusable template for documenting gastroenterology follow-up visits, including current gastrointestinal symptoms, relevant history, medications, test results, assessment, and differential diagnoses. It also supports recording the treatment plan, referrals, investigations, and patient education.
Gastroenterologist
- General Dentist Referral to Dental SpecialistA reusable referral letter for general dentists sending patients to specialist dental practitioners. It captures clinician and specialist details, the referral rationale, relevant clinical history, examination and diagnostic findings, requested care, urgency, and supporting attachments.
Dentist
- Initial Workers' Compensation ConsultationA concise template for documenting an initial workers' compensation consultation. It covers the injury history, symptoms, medical background, examination, diagnosis, work capacity, and management plan.
General Practitioner
- Patient Care PlanA Family Medicine template for documenting the visit summary, care plan, prescribed medications, follow-up arrangements, and other patient-specific recommendations.
Family Medicine Specialist
- GP Telephone ConsultationA reusable template for documenting general practitioner telephone consultations. It captures the caller and reason for contact, reported history, remotely available findings, clinical assessment, treatment, medication changes, referrals, and follow-up instructions.
General Practitioner
- Dermatology Lesion Assessment and Follow-Up NoteA structured template for documenting dermatological skin-lesion assessments, including the diagnosis, relevant history, clinical examination, management, and follow-up. It supports clear communication with the referring GP and records whether further investigation or treatment is planned.
Dermatologist
- Meeting NoteA structured template for recording clinical team meetings, including logistical details, attendees, agenda items, discussion points, action items, and plans for the next meeting. It supports organized follow-up for team coordination, case discussions, and planning sessions.
Clinical Social Worker
- Initial Urogynaecology Prolapse And Incontinence AssessmentThis template structures an initial consultation for urinary incontinence and/or prolapse. It covers patient details, presenting history, bowel and fluid habits, medical and social background, examination, assessment, treatment planning, and follow-up.
Obstetrician & Gynaecologist
- Emergency Medical Services ReportA reusable EMS documentation template for recording patient information, dispatch and arrival details, health history, vital signs, examination findings, substance-use indicators, procedures, transport changes, and signatures. It supports clear documentation of events and care during an emergency response.
Emergency Medicine Specialist
- Internal Medicine Progress NoteA structured template for comprehensive internal medicine follow-up documentation. It organizes physical examination findings, diagnostic testing, problem-oriented assessment and treatment plans, and health maintenance activities.
Internal Medicine Specialist
- OT Progress NoteA concise structure for documenting occupational therapy sessions, including attendance, session focus, client presentation and participation, discussions, homework, and the plan. It supports clear recording of only the details explicitly available in the provided information.
Occupational Therapist
- New patientA reusable respiratory medicine template for documenting a new patient’s profile, history, symptoms, examination findings, investigations, and current treatment considerations. It also structures impressions and recommendations related to sleep and breathing concerns.
Respiratory Physician
- Occupational Therapy Initial Telephone Consultation NoteA reusable occupational therapy documentation structure for recording client details, referral context, an initial telephone consultation, recommendations, and next steps. It supports assessment planning for sensory sensitivities, social communication difficulties, daily living skills, and independent living.
Occupational Therapist
- Speech Therapy Progress NoteThis template supports Speech Pathologists in documenting client attendance, progress, goals, session activities, homework, and recommendations. It provides a structured record of speech therapy sessions and follow-up care.
Speech Pathologists
- EMDR SessionA structured template for documenting pediatric EMDR therapy sessions, including the patient’s presentation, session content, target components, processing outcomes, and plan for follow-up.
Pediatric Psychologist
- Team MeetingThis template structures documentation of multidisciplinary care team meetings, including participants, agenda topics, patient details, discussion points, assigned actions, and plans for the next meeting. It supports clear coordination of treatment and follow-up for complex patient care.
Clinical Social Worker
- GP Detailed Symptom History TemplateA reusable template for documenting a detailed history of present illness, including the chief complaint, symptom characteristics, associated symptoms, relevant context, risk factors, functional impact, and preliminary next steps. It is intended to support comprehensive clinical history-taking and initial assessment across a broad range of presentations.
General Practitioner
- Psychologist Therapy Session Progress RecordA structured template for documenting psychotherapy sessions, including the patient's presentation, mental health concerns, functional impact, risks, interventions, progress, and response to treatment. It supports clear tracking of therapeutic themes, changes, challenges, and emotional or behavioural developments.
Psychologist
- GP Medical Certification For Leave Or ClaimsA reusable structure for general practitioners to document a patient's condition, diagnostic assessment, treatment plan, prognosis, and work or disability recommendations for medical leave or claims. It also organizes the administrative details, supporting findings, referrals, follow-up, and certification required for clear medical reporting.
General Practitioner
- Suicide Risk AssessmentA structured template for documenting a client's suicide risk, including overall and summary assessments, priority populations, previous attempts, risk and protective factors, and warning signs. It supports concise, clinically relevant communication while requiring that only explicitly provided information be included.
Psychologist
- Internal Medicine Follow-Up Visit NoteA reusable template for documenting internal medicine follow-up visits, covering the referral reason, updated history, examination findings, discussion summary, and concise management plan. It supports follow-up care for ongoing conditions, including hypertension and diabetes.
Internal Medicine Specialist
- Parent-only sessionA structured template for documenting a session held with a child's parent or parents about the child's mental health. It covers the session summary, clinical impression, follow-up actions, the next appointment, and the focus of the next session.
Pediatric Psychologist
- UK GP ConsultationA structured template for documenting UK general practice consultations, from the patient's presenting concerns and clinical assessment through examination, treatment, prescribing, risk review and follow-up. It supports concise recording of explicitly stated consultation information in a consistent format.
General Practitioner
- Procedure NoteA structured template for documenting minor procedures, including the indication, relevant history, examination findings, assessment, consent, procedural details, aftercare, and follow-up. It supports clear recording of laceration repairs and other office-based interventions.
General Practitioner
- Patient Letter Following Initial Neurology ConsultationA reusable template for writing a patient-addressed letter after an initial neurology consultation. It covers diagnoses, management, symptoms, medical and family history, medicines, social circumstances, investigations, neurological examination, differential diagnosis and the proposed management plan.
Neurologist
- Clinical Supervision Meeting SummaryA structured template for documenting clinical supervision meetings, including participants, agenda items, discussion points, agreed actions, follow-up, and the next meeting. It supports clear records of supervision, accountability, and ongoing professional development.
Psychologist
- New Patient Clinic LetterA concise correspondence template for orthopaedic new-patient consultations, covering the referral response, diagnosis, history, examination, investigations, treatment, and management plan. It supports clear communication with the referring clinician while including only information explicitly provided.
Orthopaedic Surgeon
- Psychiatric Discharge SummaryA structured template for documenting psychiatric admissions and discharges, including patient identification, presenting illness, psychiatric and medical history, investigations, medications, mental status examinations, hospital course, discharge planning, and diagnoses.
Psychiatrist
- General Practice Chronic Condition PlanA structured template for documenting a General Practice Management Plan for a patient with a chronic condition. It covers patient and GP details, assessment, relevant history, current needs, goals, agreed actions, lifestyle measures, monitoring, medications, immunisations, complications, and mental health and wellbeing.
General Practitioner