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 12 of 13

Psychotherapeutisches Sitzungsprotokoll
Diese Vorlage strukturiert die Dokumentation einzelner psychotherapeutischer Sitzungen. Sie erfasst Sitzungsinhalte, Interventionen, Veränderungen, Interaktionsverhalten, psychisches Befinden sowie neue Vereinbarungen und die Planung der nächsten Sitzung.
General Practitioner
Comprehensive ADHD and Psychological Evaluation Report
A structured report template for comprehensive psychosocial, psychological, and ADHD evaluations. It covers identifying information, referral concerns, background history, mental health and ADHD symptoms, diagnostic impressions, recommendations, conclusions, and clinician sign-off.
Psychologist
Pediatric Behavioral Health Intake and Follow-Up
A structured template for documenting pediatric behavioral health intake and follow-up visits. It covers presenting concerns, developmental and psychiatric history, medications, rating scales, mental status, safety, assessment, treatment planning, follow-up communication, billing, and care-team tasks.
Psychiatrist
Inpatient Intake Note
A reusable inpatient admission documentation template for capturing the patient’s presenting concerns, psychiatric and medical history, medications, substance use, examination findings, safety considerations, assessment, treatment plan, and follow-up information. It is designed to support comprehensive documentation of complex inpatient cases.
Psychiatrist
Comprehensive Psychiatric Assessment Note
A structured template for documenting comprehensive psychiatric consultations, including presenting concerns, psychiatric and medical history, substance use, family and legal history, mental status examination, and clinical recommendations. It supports clear, efficient recording of assessment and treatment planning information.
Psychiatrist
Family Medicine Note
A reusable template for documenting comprehensive family medicine visits, including presenting concerns, relevant history, review of systems, examination findings, investigations, and assessment and plan. It also supports recording ICD10 and CPT codes for clinical documentation and billing.
Family Medicine Specialist
Gynaecology Consultation
A structured template for documenting comprehensive gynaecology consultations. It covers the presenting concerns, medical and menstrual history, social history, investigations, discussion of contraception and PCOS, and the assessment and follow-up plan.
Gynaecologist
BIRP (Couple)
A structured template for documenting couple therapy sessions, including the partners’ observed behavior, therapeutic interventions, responses, and follow-up plans. It supports organized recording of relationship dynamics, communication concerns, and ongoing treatment planning.
Therapist
Letter to Referrer
A reusable letter structure for updating a referring clinician about a patient's assessment, relevant history, findings, and care plan. It supports clear communication and continuity of specialist care.
Neurosurgeon
Urology Patient Telephone Encounter Note
This template is for concise documentation of telephone interactions involving a urology patient or the patient’s representative. It records the caller’s identity and relationship, the call purpose, the discussion, actions, follow-up, and any other explicitly stated details.
Urologist
Pediatric Surgery Referral Update Letter
This template is for surgeons writing structured updates to referring physicians. It covers the referral reason, diagnosis, treatment plan, examination findings, procedural details, related information, and follow-up communication.
Pediatric Surgeon
Psychiatric Individual Therapy Intake Note
A reusable structure for documenting an individual’s initial therapy session, including presenting concerns, psychological, biological, and social factors, clinical assessment, risk, interventions, goals, and follow-up planning. It supports comprehensive assessment and individualized treatment planning without pre-populating any clinical information.
Psychiatrist
Addiction Consultation
A structured template for documenting comprehensive addiction medicine consultations. It covers the reason for referral, presenting illness, substance use and social history, prior treatment, medications, examination, investigations, assessment, and plan.
Nurse Practitioner
ENT Note
A reusable otolaryngology template for documenting chief complaints, assessment, subjective history, examination findings, endoscopic observations, and follow-up planning. It supports concise yet comprehensive records for ENT consultations and ongoing care.
Otolaryngologist
Emergency Dental Consultation
A structured template for documenting urgent dental consultations involving pain, infection, or trauma. It covers the presenting complaint, relevant history, examination, diagnostics, emergency treatment, patient advice, and follow-up planning.
Dentist
New Urology Patient
This template structures an initial urology consultation for a new patient. It covers the chief complaint, present illness, relevant histories, examination, issue-specific assessment and plan, orders, follow-up, and a brief visit summary.
Urologist
Ongoing Session Template
A reusable structure for documenting the main content of an ongoing mental health session, the therapeutic techniques used, progress toward goals, identified risks, and the plan for the next session.
Counselling Psychologist
Social Work Encounter Documentation Template
A reusable template for documenting social work encounters, including client information, referral details, presenting concerns, social and medical history, assessment, interventions, and care planning. It supports comprehensive recording of explicitly documented psychosocial needs, services provided, risks, and follow-up actions.
Social Worker
Colorectal Cancer Consultation
A structured template for documenting colorectal cancer consultations, including presentation, diagnosis, history, investigations, examination, impression, and follow-up planning. It supports detailed surgical and multidisciplinary care documentation.
Colorectal Surgeon
GP Weight Management Consultation Note
A concise structure for documenting weight management consultations, including presenting concerns, relevant history, lifestyle factors, examination measurements, personalised advice, and Mounjaro use instructions.
General Practitioner
General Head-to-Toe Physical Assessment
A reusable template for documenting a comprehensive head-to-toe physical examination. It covers the patient’s history and findings across integumentary, head and neck, sensory, cardiopulmonary, abdominal, genitourinary, rectal, musculoskeletal, and neurological assessments.
Nurse
Child and Adolescent Psychiatry Intake Evaluation
A structured template for comprehensive child and adolescent psychiatric intake evaluations. It organizes presenting concerns, psychiatric and medical history, symptom review, mental status, rating scales, formulation, risk, treatment, collaboration, and safety planning.
Child and Adolescent Psychiatrist
Psychiatric Assessment – First Appointment
A structured template for documenting a first psychiatric assessment. It covers referral concerns, psychiatric and medical history, personal and family background, mental state, risk, formulation, diagnosis, management, and capacity and consent.
Psychiatrist
Hospitalist H&P
A comprehensive inpatient admission template for documenting the presenting concern, history, review of systems, examination, investigations, and problem-based assessment and plan. It also captures two-midnight documentation and total time spent.
Physician
Psychiatry Initial Consultation
A reusable template for documenting a patient's initial psychiatric consultation. It covers the presenting concern, symptoms, psychosocial and clinical history, mental status examination, assessment, and treatment plan using only explicitly provided information.
Psychiatrist
Employee Supervision Plan
A structured template for supervising healthcare employees, covering responsibilities, SMART performance goals, development needs, support arrangements, evaluation criteria, challenges, and review timelines. It also records employee input and the commitments of both parties.
Healthcare Service Manager
Urology Follow-Up Note
A reusable template for documenting follow-up urology encounters, including the presenting concerns, relevant urological history, current symptoms and investigations, examination, assessment, treatment planning, orders, and follow-up.
Urologist
CBT Session
This template structures documentation of cognitive-behavioural therapy sessions, including objectives, progress review, current patient concerns, cognitive and behavioural interventions, homework, and the plan for the next session. It supports consistent tracking of therapeutic work and patient progress.
Psychiatrist
Annual Hearing Test and Hearing Aid Check
A reusable audiology template for annual hearing assessments and hearing aid reviews. It captures medical and hearing-history updates, test findings, device maintenance and verification, education, and follow-up planning.
Audiologist
Emergency Surgery Ambulatory Follow-up Letter
A structured letter for general surgeons documenting follow-up visits in the Emergency Surgery Ambulatory Care setting. It captures the diagnosis, investigations, treatment plan, relevant history, examination findings, results, and ongoing follow-up for patients after or around surgical care.
General Surgeon
Childhood Adversity Screening and Health Impact Review
A structured template for documenting reported childhood adversity before age 18 and calculating a total ACE score. It also records the patient's reported perception of how these experiences have affected their overall health.
Psychiatrist
Cardiology Consult
A structured template for comprehensive cardiology consultations, covering cardiovascular risk factors, cardiac and medical history, medications, allergies, social context, symptoms, examination, investigations, assessment, management, and follow-up.
General Practitioner
Psychiatric Assessment Letter
A structured template for documenting comprehensive psychiatric assessments, including presenting concerns, medical and psychiatric history, developmental and social context, mental state examination, risk assessment, formulation, treatment planning, and capacity. It is intended to support clear, organised communication with primary care colleagues.
Psychiatrist
Pelvic Health Follow-Up Issues List
A structured follow-up template for physiotherapists documenting pelvic health concerns, patient-reported symptoms, goals, examination findings, interventions, and ongoing plans. It supports issue-by-issue recording across bladder, bowel, prolapse, sexual, pelvic floor, and musculoskeletal care.
Physiotherapist
Initial Biomechanical Podiatry Assessment
A reusable template for documenting an initial podiatric biomechanical assessment. It covers the presenting complaint, injury history, activity levels, footwear and orthotics, patient goals, clinical assessment, gait, treatment, prescribed exercises, and follow-up planning.
Podiatrist
Outpatient Occupational Therapy Evaluation Template
A structured template for documenting an initial outpatient occupational therapy assessment. It covers referral details, occupational profile, client goals, functional performance, cognitive and psychosocial factors, environmental context, assessment findings, and explicitly stated recommendations.
Occupational Therapist
Women’s Medicare Annual Wellness Assessment
A reusable structure for documenting a female Medicare annual wellness visit, including patient and visit details, chronic conditions, medical history, preventive care, risk assessments, care planning, counseling, and follow-up. It is designed to capture only information explicitly provided while keeping undocumented sections out of the completed note.
Sports physician
Case Conference Report
A reusable report structure for documenting multidisciplinary case conferences, including patient details, conference logistics, attendees, discussed issues, care planning, follow-up, and explicitly stated MBS billing information.
General Practitioner
DSM-V Criteria
This template structures documentation of the DSM-V diagnostic criteria for Autism Spectrum Disorder. It covers social communication and interaction, restricted or repetitive behaviours, developmental onset, functional impact, and differential diagnostic considerations.
Speech and Language Therapist
Cosmetic Injectables
This template structures documentation for aesthetic injectable consultations and treatments. It covers patient information, relevant history, ageing concerns, planned and administered injectables, costs, ongoing treatment, and after-care instructions.
Nurse
Staff Training Summary
A reusable template for documenting staff training sessions, including objectives, covered topics, techniques, practical exercises, staff feedback, and follow-up needs.
Psychologist
ADIME Initial Nutrition Intake
A structured ADIME template for documenting an initial nutrition assessment, diagnosis, intervention, and follow-up evaluation. It covers nutritional history, measurements, relevant clinical data, goals, care planning, and monitoring indicators.
Nutrition & diabetics Specialist
NDIS Support Letter
A structured template for paediatricians to document a child's diagnosed disability, functional, social and economic impacts, previous treatments, and recommendations for ongoing or future NDIS supports.
Paediatrician
Dermatology Consultation Communication Letter
A reusable letter structure for documenting dermatology diagnoses, relevant history, examination findings, clinical summary, management, GP actions, and follow-up. It supports clear communication with other healthcare professionals while capturing the information needed for coordinated patient care.
Dermatologist
Naturopathic Treatment Plan
A reusable template for documenting a personalized naturopathic care plan, including patient goals, testing and medical discussions, records, referrals, resources, supplements, lifestyle recommendations, and timelines for follow-up planning.
Naturopath
NDIS Goal-Focused Therapy Session Note
A concise template for documenting NDIS capacity building therapy sessions delivered by Accredited Mental Health Social Workers. It captures participant and therapist details, the session focus, progress toward NDIS goals, feedback, observations, recommendations, duration, and signature information.
Accredited Mental Health Social Worker
GP Menopause Consultation Template
A structured template for documenting assessment and care of patients experiencing perimenopause or menopause. It covers relevant history, examination, investigations, treatment discussions, preventive advice, team involvement, and follow-up.
General Practitioner
Initial GP Letter
A concise letter template for communicating an initial mental health consultation to a referring clinician. It covers the referral details, relevant session findings, DASS results, treatment plan, follow-up timing, and clinician contact information.
Psychologist