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 11 of 13

Psychology Session Notes
This template structures psychology follow-up or progress documentation. It covers out-of-session tasks, current presentation, session content, interventions, treatment barriers and progress, risk assessment, mental status examination, and planning for the next session.
Psychologist
Physiotherapy Initial Assessment
A structured template for documenting an initial physiotherapy consultation, including subjective history, general health, red-flag screening, patient-centred ICE information, objective examination findings, clinical analysis, and follow-up planning.
Physiotherapist
Head & Neck MDT
A reusable template for documenting multidisciplinary team meetings concerning patients with head and neck cancer. It covers patient details, clinical history, examination, investigations, diagnosis, treatment planning, MDT discussions, recommendations, and subsequent management steps.
Nurse
Midwife Postnatal Notes
A structured template for midwives to record a mother's postnatal health after childbirth. It covers maternal physical and emotional assessment, breastfeeding, bonding, education, referrals, care planning, and the baby's initial postnatal assessment.
Midwife
Urology Office Consult
A reusable template for urologists to prepare concise consultation reports for referring physicians. It covers the referral reason, presenting history, urinary and related symptoms, medical and social background, examination, investigations, assessment, and management plan.
Urologist
Practice Meeting Minutes
A reusable template for documenting healthcare practice meetings, including attendees, agenda topics, discussion points, decisions, action items, and plans for the next meeting.
General Practitioner
Psychiatric Medication Review Note
A structured template for documenting a patient's current psychiatric medication regimen, including adherence, side effects, effectiveness, and concerns. It also organises the assessment, medication plan, education, testing, and follow-up information.
Psychiatrist
Physiotherapy Progress Update for Referring Doctor
A reusable letter structure for physiotherapists and other allied health clinicians to update referring doctors on a patient's assessment, treatment, and rehabilitation progress. It covers patient and recipient details, initial findings, care provided, and the patient's response since referral.
Physiotherapist
Referral Note
A reusable referral template for documenting a patient's age, current symptoms, treatments already attempted, and diagnostic workup when communicating with another healthcare provider.
Family Medicine Specialist
Occupational Therapy Functional Capacity Assessment
A reusable occupational therapy assessment template for documenting client details, health and support contexts, functional abilities, home circumstances, self-care, daily living skills, and goals. It is suited to comprehensive functional capacity assessments, including NDIS-related information.
Occupational Therapist
Cardiology Consultation Note
A structured template for documenting cardiology consultations, including cardiac risk factors, medical and cardiac history, medications, examination, investigations, assessment, management, and follow-up. It supports concise narrative documentation while retaining detailed cardiovascular information and explicit follow-up planning.
Cardiologist
Child and Adolescent Psychiatry Assessment
A comprehensive structure for documenting an initial child or adolescent psychiatry assessment. It covers referral concerns, developmental, medical, psychiatric, family and social history, mental status, risk, psychometrics, diagnostic formulation and treatment planning.
Child and Adolescent Psychiatrist
Braces and Invisalign Consultation Note
A reusable orthodontic consultation template for documenting patient and referral details, relevant histories, examination and diagnostic findings, treatment options, recommendations, consent, education, and follow-up planning. It supports clear discussion of braces and aligners while recording patient or guardian questions, preferences, risks, benefits, and alternatives.
Orthodontist
Paediatric Review Letter
A structured template for comprehensive paediatric review documentation, covering medical problems, medications, school and home progress, supports, mental health, daily habits, examination findings, summary and plan.
Paediatrician
DARP Progress Note
A reusable DARP template for documenting mental health therapy sessions across Data, Assessment, Response, and Plan. It captures subjective and objective information, interventions, client responses, clinical progress, treatment goals, and follow-up actions.
Psychiatrist
ABCD Dietetics Consultation
A structured template for documenting dietetic consultations, including goals, anthropometry, biochemistry, clinical information, dietary history, assessment, and the dietetics plan. It supports consistent recording of recommendations, education, follow-up, and other relevant clinical details.
Dietitian
Six-Week Paediatric Check
A structured template for documenting an infant’s six-week review, including birth history, feeding, growth, development, examination findings, and follow-up planning. It supports concise, comprehensive paediatric documentation without adding information that was not provided.
Paediatrician
Psychodynamic Psychotherapy SOAP Note
A structured SOAP template for documenting psychotherapy sessions from a psychodynamic/object-relations perspective. It covers the patient's subjective experiences, observed emotional and cognitive functioning, therapeutic assessment, and plans for continued intervention.
Psychologist
Hospital Discharge Summary
A reusable template for documenting a patient's hospital course, including treatments, significant events, changes in condition, and interventions. It also captures explicitly stated follow-up guidance and patient education to support continuity of care after discharge.
Internal Medicine Specialist
Comprehensive ASD and ADHD Evaluation Report
A structured template for comprehensive assessments of Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD). It covers developmental, educational, employment, social, medical, psychiatric, substance-use, risk, mental state, ADHD symptom, and autistic symptom information, including ADOS observations and Autism Quotient scoring.
Psychologist
Paediatric Functional Capacity Assessment
A structured template for occupational therapists to document a child’s functional abilities, support needs, developmental history, daily activities, participation, communication, emotional regulation and behaviours of concern. It also captures relevant family, clinical, educational and community supports for planning care and interventions.
Occupational Therapist
Adult Autism Observation And Communication Assessment Report
A structured template for documenting an adult Autism Diagnostic Observation Schedule (ADOS-2) assessment. It covers referral context, developmental and behavioural information, observed social communication, ADOS-2 scoring, clinical formulation, recommendations, and follow-up.
Psychiatrist
Initial Autism Assessment Report
A structured template for documenting the initial phase of an autism assessment. It covers referral context, assessment methods, developmental history, clinical observations, relevant domains of functioning, preliminary formulation, risk, conclusions, recommendations, and capacity.
Psychiatrist
Cardiology Specialist Assessment Letter for GP
A formal UK general practitioner letter template for communicating a specialist assessment after referral. It covers referral context, patient history, examination findings, diagnoses, investigations, medications, management recommendations, follow-up, and clinician details.
Cardiologist
Emergency Trauma Assessment
A structured template for documenting the initial emergency trauma evaluation, including pre-arrival information, EMS hand-off, trauma team details, and the ABCDE primary survey. It captures vital signs, airway, breathing, circulation, neurological and cervical spine findings, exposure, and major interventions.
Emergency Medicine Specialist
General Practice SOAP Note
A structured SOAP note template for general practice visits. It organizes subjective symptoms and history, objective findings, and issue-based assessments and plans, including documentation for multiple presenting concerns.
General Practitioner
Nurse Practitioner Problem-Oriented Visit Note
A structured template for documenting visits organized by patient issue, including the history of present illness, review of systems, physical examination, and assessment and plan. It supports systematic evaluation and management of multiple concerns, with space for diagnoses, differentials, investigations, treatments, and referrals when applicable.
Nurse Practitioner
Trauma-Focused EMDR Therapy Session Note
This template is for documenting EMDR therapy sessions for trauma-related concerns. It covers the presenting issue or memory, core EMDR assessment elements, processing phases, closure procedures, and topics for future sessions.
Therapist
Work Absence Verification Letter
A reusable letter template for documenting a patient's work absence due to an explicitly stated illness or condition, including the relevant period and any explicitly documented return-to-work status. It also provides space for the clinician's name and contact information when supplied.
Counselors
Bladder cancer cystoscopy follow-up
A structured urology follow-up template for patients with a history of bladder cancer. It captures cancer and procedure history, current symptoms and investigations, office cystoscopy findings, assessment and plan, orders, and follow-up.
Urologist
Nutrition Intake Note
A reusable structure for documenting a comprehensive nutrition assessment, including medical and social history, food-related experiences, dietary patterns, nutritional symptoms, eating behaviors, goals, recommendations, and follow-up planning.
Dietitian
Prostatectomy Follow-up
A structured urology follow-up template for documenting recovery after prostatectomy. It covers prostate cancer history, recovery milestones, current symptoms and test results, examination, assessment and plans, orders, and follow-up.
Urologist
Antenatal Visit
This template supports comprehensive antenatal documentation by covering prenatal history, examination findings, assessment, care planning, education, and ongoing support. It is intended to help midwives record gestational progress, foetal wellbeing, birth preferences, and preparation for continuing care.
Midwife
Physiotherapy Progress Review Note
A structured template for documenting physiotherapy follow-up visits. It covers subjective progress, objective findings, treatment, reassessment, problem analysis, and the plan for ongoing care and home exercises.
General Practitioner
Gastroenterology Treatment Review Note
A reusable template for documenting gastroenterology follow-up appointments, including the patient’s history, relevant prior conditions, recent investigations, clinical impressions, and management plan. It supports assessment of treatment response, therapy changes, monitoring, and lifestyle guidance for ongoing gastrointestinal care.
Gastroenterologist
Adult Intake
A structured template for documenting an adult client’s initial psychotherapy assessment. It covers presenting concerns, relationships, living situation, education or employment, physical and mental health history, therapy goals, initial impressions, and the plan for the next session.
Psychotherapist
Concise Consultation Summary and Patient Message
A reusable template for producing a brief consultation summary followed by a clear, patient-friendly post-consultation message. It covers agreed next steps, warning signs, follow-up arrangements, and when to contact the clinic.
General Practitioner
Pain Management Triage
A structured template for documenting an injury history, current pain experience, relevant medical information, cultural or individual considerations, and the effects of pain on daily functioning and quality of life.
Physical Medicine and Rehabilitation Specialist
Psychiatric Follow-Up Care Letter
A reusable letter for summarizing a psychiatric visit and outlining the patient’s ongoing care. It covers the treatment plan, medications, next appointment, referrals, pharmacy information, and clinician contact details.
Psychiatric Nurse
Child And Adolescent Mental Health Assessment
A structured template for comprehensive Child and Adolescent Mental Health Services assessments. It covers presenting concerns, developmental and social history, mental state, risk, goals, formulation, care planning, and the young person’s wellbeing preferences.
Mental Health and Behavioural Specialist
BPSD
A structured template for documenting behavioural and psychological symptoms of dementia in a comprehensive geriatric assessment. It covers presenting issues, cognitive and functional history, examination findings, medications, social context, treatment recommendations, and follow-up planning.
Geriatrician
Psychiatric Intake
A structured template for initial psychiatric evaluations, covering presenting concerns, psychiatric and medical history, substance use, psychosocial context, mental status findings, assessment, treatment planning, and diagnostic and billing information.
Psychiatric Nurse
Palliative Consultation
A reusable template for documenting palliative care consultations, including patient details, presenting concerns, medical and social history, symptom review, objective findings, assessment, and care planning. It supports structured documentation of symptom management, goals of care, and follow-up for complex patients.
Family Medicine Specialist
Cardiology Consultation Update Letter
A cardiology correspondence template for updating a referring physician about a patient's cardiovascular history, risk profile, medications, symptoms, examination, investigations, assessment, and follow-up. It supports clear communication of explicitly documented information and ongoing care plans.
Cardiologist
Speech Articulation Assessment
A reusable speech pathology template for documenting a child’s articulation assessment, treatment performance, parent education, home practice, and follow-up plan. It covers relevant history, examination findings, clinical impression, goals, interventions, and future therapy arrangements.
Speech Pathologists
Emergency Department Clinical Assessment Note
A comprehensive emergency department physician template for documenting the presenting complaint, relevant history, examination, investigations, clinical assessment, treatment, disposition, and follow-up. It is structured for first-person clinician documentation using explicitly provided information only.
Emergency Medicine Specialist
Orthopaedic Assessment Letter for Referring GPs
A structured letter template for orthopaedic surgeons to communicate new-patient assessment findings and management plans to referring GPs. It covers the primary diagnosis, treatment plan, patient history, examination, investigations, and treatment discussions using only explicitly documented information.
Orthopaedic Surgeon
SOAP (T&E)
A structured mental health therapy-session template for documenting the client’s reported symptoms, session themes, therapeutic interventions, assessment information, progress, and ongoing treatment plan.
Mental Health Counselor