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 10 of 13
- General Practice Comprehensive Consultation NoteA reusable template for systematically documenting comprehensive patient information during consultations. It covers demographics, vital signs, medical and immunization history, medications, allergies, diagnoses, diagnostic results, treatment planning, and patient education.
General Practitioner
- Internal Medicine Hospital Discharge SummaryA structured discharge summary template for Internal Medicine documentation. It captures admission and discharge dates, responsible and pre-existing diagnoses, hospital interventions and course, medications, discharge destination, follow-up instructions, allergies, end-of-life details, and completed forms.
Internal Medicine Specialist
- SOAPIE - PhysiotherapyA structured physiotherapy documentation template for recording a patient visit using the SOAPIE framework. It covers subjective information, objective findings, assessment, treatment planning, interventions, and evaluation of progress.
Physiotherapist
- General follow-upThis template structures internal medicine follow-up documentation, covering subjective complaints, relevant history, examination findings, assessment, and plan. It supports monitoring ongoing and chronic conditions, including medication adherence, diagnostic testing, referrals, and continuity of care.
Internal Medicine Specialist
- Rehabilitation Team Meeting RecordA reusable template for occupational therapists and other rehabilitation professionals to record team meetings. It organizes attendees, agenda items, discussion points, decisions, action items, and details for the next meeting to support therapy planning, progress tracking, and multidisciplinary care coordination.
Occupational Therapist
- Diabetes ReviewA structured template for documenting diabetes follow-up, including current treatment, recent progress, and the planned management approach. It also captures monitoring, lifestyle advice, education, complication screening, and possible future treatment changes.
General Practitioner
- Follow-upThis psychiatric follow-up template structures documentation of ongoing care, including presenting complaints, mental status, risk, diagnoses, treatment, safety planning, and additional information. It supports consistent tracking of medication adherence, mood, cognition, and treatment progress across visits.
Psychiatrist
- Therapy and Medication Review NoteA reusable template for documenting psychotherapy sessions alongside medication management. It covers the patient’s concerns and progress, interventions, mental status findings, medications, safety, diagnostic and billing information, follow-up communication, and assigned tasks.
Psychiatrist
- ENT ConsultationA structured template for otorhinolaryngology consultations, covering presenting history, examination, investigations, assessment, management, and follow-up. It also provides conditional patient-information sections for commonly discussed ENT procedures and their risks.
Otorhinolaryngologist (ENT Specialist)
- ED AssessmentA structured template for documenting emergency department assessments, including the presenting complaint, relevant history, examination, investigations, clinical impression, outcome, and management plan. It supports concise recording of acute presentations while preserving key findings, decisions, follow-up, and safety-netting information.
Emergency Medicine Specialist
- CaP Active SurveillanceA structured urology template for documenting follow-up visits for a man with prostate cancer managed with active surveillance. It captures the cancer history, biopsy and MRI findings, PSA and PSA density, current assessment, management plans, orders, and follow-up considerations.
Urologist
- Gynaecology ConsultA structured template for documenting comprehensive gynaecological consultations, including the current concern, gynaecologic, sexual and obstetrical histories, medical and family history, examination findings, investigations, and the impression and plan.
Obstetrician & Gynaecologist
- Family Medicine Specialist Note (Canada)A structured template for Canadian family medicine specialists to document visits, including ICD-9 diagnoses, Saskatchewan billing codes, subjective and objective findings, and problem-based assessment and planning. It supports comprehensive documentation of medical history, medications, examinations, investigations, and management decisions.
Family Medicine Specialist
- Initial HistoryThis template supports adult audiology initial assessments by organising the patient’s hearing and communication concerns, ear and general health history, hearing aid experience, test findings, and follow-up planning. It is intended for comprehensive, explicit-only clinical documentation.
Audiologist
- Nephrology Consultation Update LetterA professional correspondence template for updating a referring practitioner about a patient's kidney-related consultation. It organises the visit details, explicitly documented clinical findings, diagnosis, management, recommendations, and clinician contact details.
Nephrologist
- Meeting Summary and Action PlansA reusable structure for recording the main discussion points, decisions, concerns, and agreed follow-up actions from a meeting. It captures responsibilities and timeframes when they are explicitly provided.
General Practitioner
- Outcome LetterA reusable letter structure for psychologists to communicate consultation outcomes to patients or other healthcare professionals. It covers the consultation summary, investigations and findings, diagnosis, treatment, medication, and follow-up arrangements.
Psychologist
- NDIS Psychology Session Progress NoteA structured template for documenting psychology sessions with NDIS participants. It captures presentation, goals, therapeutic work, risks, engagement, functional capacity, progress, and follow-up planning using only explicitly provided information.
Psychologist
- Optometrist's NoteA structured optometry examination template for documenting the patient’s concerns, relevant ocular and medical history, examination findings, assessment, prescriptions, management, education, referrals, and follow-up. It covers visual acuity, refraction, intraocular pressure, anterior and posterior segment findings, and additional investigations.
Optometrist
- Medical Narrative Report NotesA reusable template for preparing comprehensive medical narrative reports about work-related injuries. It covers the patient’s background, injury and examination findings, investigations, treatment, progress, prognosis, medical opinion, recommendations, and certification details.
General Practitioner
- Psychology Team MeetingA reusable structure for documenting psychology and mental health team meetings. It captures meeting logistics, attendees, agenda discussions, decisions, action items, and arrangements for the next meeting.
Psychologist
- Orthopaedic Progress NoteA structured template for documenting orthopaedic follow-up visits, including subjective symptoms, examination findings, assessment, treatment planning, and relevant patient discussions.
Orthopaedic Surgeon
- Multi-Issue GP ConsultationA reusable Australian general practice consultation structure for documenting one or more clinical issues. It covers presenting history, examination, mental state findings where relevant, impressions, and issue-specific plans including investigations, treatment, referrals, safety netting and follow-up.
General Practitioner
- Hospice Care Preferences And Symptom Management NoteThis template supports structured hospice documentation covering patient identification, care preferences, symptom management, emergency orders, communication, and legal compliance. It is designed to keep the hospice team aligned while documenting comfort-focused care and the patient’s stated wishes.
Nurse
- Allergy and Immunology ConsultationA structured consultation template for documenting allergy and immunology assessments, including atopic symptoms, medical and family history, examination, testing, clinical impression, and follow-up. It supports consistent evaluation and management planning for allergic and immune-related conditions.
Allergy and Immunologist
- Telephone Consultation LetterA reusable letter structure for documenting telephone consultations with patients. It captures the call details, patient-facing summary, advice, and agreed follow-up, along with clinician sign-off information.
Neurologist
- Medical Absence Letter TemplateA reusable letter structure for documenting and communicating a patient's medically recommended absence from work or school. It captures the relevant dates and clinician identification details without inventing any missing information.
Family Medicine Specialist
- Implant AssessmentThis template structures a comprehensive dental implant assessment, covering patient details, presenting concern, medical, dental and social history, and clinical findings. It also records implant-site and periodontal evaluations, imaging, investigations, risk categories, diagnosis, treatment planning, prognosis, and follow-up.
Dentist
- Comprehensive Initial Dietetic ConsultationA structured template for initial dietetic consultations, covering medical and nutrition history, dietary intake, lifestyle factors, assessment, diagnosis, education, intervention, and follow-up planning. It supports a holistic review of nutritional status and the creation of individualized nutrition and lifestyle goals.
Dietitian
- Initial Work Injury Physiotherapy AssessmentThis template is for documenting an initial physiotherapy assessment for a work-related injury. It covers the presenting condition, investigations, medical and employment history, goals, objective findings, treatment, assessment, and follow-up planning.
Physiotherapist
- Detailed SOAP NoteThis template structures a comprehensive SOAP note for documenting a patient encounter. It covers subjective history, objective findings, assessment, and plan, including relevant investigations, treatment, education, referrals, and follow-up information.
Naturopath
- Respiratory ClinicA structured template for documenting respiratory consultations, including respiratory and other medical problems, medications, investigations, current discussion, impression, management, GP actions, and patient takeaways. It supports efficient capture of explicitly stated clinical information without adding diagnoses or recommendations.
Respiratory Physician
- Lecture and Webinar NotesA reusable template for documenting medical lectures and webinars, including their topics, key takeaways, discussion points, resources, and personal reflections. It supports structured continuing medical education notes and future reference.
Physician
- Follow-up NoteThis template structures oncology follow-up documentation, covering the diagnosis, prior and current clinical information, examination findings, diagnostic results, assessment, treatment planning, and referrals. It is intended to support consistent recording of cancer care and treatment progress.
Medical Oncologist
- Counsellor Consult NoteA structured counselling note for documenting presenting concerns, session content, barriers, progress, clinical observations, and agreed next steps. It supports consistent recording of therapeutic themes, patient insights, interventions, and follow-up plans.
Counselors
- Patient Visit Summary LetterA patient-facing letter template for summarising the main points of a visit, including current concerns, relevant history, medicines, allergies, and agreed care steps. It also provides space for follow-up details and clinician contact information.
Family Medicine Specialist
- Medical Certificate for Employee Sick LeaveA structured template for documenting an employee’s medically supported absence from work. It covers practice and patient details, leave dates, consent-based illness information, workplace considerations, and healthcare provider verification.
General Practitioner
- IBD-Focused Gastroenterology ConsultationA structured template for documenting a gastroenterology consultation focused on inflammatory bowel disease. It covers the consultation reason, presenting history, IBD-specific history, medical and social background, examination, investigations, and assessment and plan.
Gastroenterologist
- Postpartum Pelvic Health Assessment NoteA reusable template for osteopaths and physiotherapists to document comprehensive postpartum pelvic health assessments. It covers obstetric history, symptoms, bowel habits, diet and lifestyle, sexual and mental health, physical activity, examination findings, and an individualized management plan.
Osteopath
- Sleep Disorder Follow-Up AssessmentA structured template for documenting follow-up care for patients with sleep disorders. It captures subjective sleep concerns, PAP therapy details, sleep and circadian patterns, daytime symptoms, objective findings, assessment, and the treatment plan.
Psychiatrist
- Compte Rendu De Consultation En Médecine GénéraleModèle structuré pour documenter une consultation de médecine générale, de l’historique et des attentes du patient jusqu’à l’examen, l’évaluation et la prise en charge. Il permet de consigner les problèmes abordés, les examens, les traitements, les orientations et le suivi uniquement à partir des informations explicitement disponibles.
General Practitioner
- Dysmenorrhoea/MenorrhagiaThis template structures documentation for consultations concerning dysmenorrhoea or menorrhagia. It covers the presenting concern, menstrual, medical and obstetric history, examination, assessment, investigations, treatment, follow-up and next steps.
General Practitioner
- Board Meeting MinutesA reusable template for documenting board meetings in an organised way, including attendance, agenda discussions, decisions, action items, and follow-up meeting details. It is designed to capture only information explicitly provided about the meeting.
Physiotherapist
- Anorectal ConsultationA structured template for documenting anorectal consultations, including referral details, presenting symptoms, relevant history, examination findings, investigations, and the assessment and plan. It supports comprehensive clinical documentation while including only information explicitly stated in the information provided.
Colorectal Surgeon
- ACT Session Progress NoteThis template structures documentation for Acceptance and Commitment Therapy sessions, covering the mental state examination, client updates, session agenda, ACT Hexaflex observations, interventions, outcomes, and follow-up.
Psychologist
- Full Skin ExaminationA reusable template for documenting a comprehensive dermatological skin examination. It covers current concerns, explicitly reported examination findings by body area, the management and follow-up plan, and applicable ICD-10 billing codes.
Dermatologist
- Nursing Initial Patient Intake TemplateA structured template for collecting core patient information during an initial healthcare visit. It covers personal details, medical and social history, current concerns, medications, provider contacts, insurance, and consent.
Nurse
- Supervision for Psychologists, Psychotherapists and CounsellorsThis template structures supervision documentation for psychologists, psychotherapists, and counsellors. It records the topics and client concerns discussed, psychological formulations, supervisor input, therapy goals, and agreed next steps.
Psychologist