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 13 of 13
- Orthopaedic Clinic Letter to PatientA patient-facing orthopaedic consultation letter covering the patient's concerns, examination findings, treatment recommendations, future management, and additional advice. It is suitable for summarising consultations about musculoskeletal conditions, including osteoarthritis.
Orthopaedic Surgeon
- Emergency Department Discharge Guidance TemplateA reusable template for documenting clear discharge guidance after an emergency department visit. It covers the diagnosis, results, treatment, medications, return precautions, patient education, and follow-up care.
Emergency Medicine Specialist
- Discuss blood resultsThis template is for documenting a discussion of blood test results with a patient. It covers patient and test details, individual results, interpretation, recommendations, and follow-up arrangements.
General Practitioner
- ADHD Basic TemplateA reusable structure for documenting paediatric ADHD assessments, including referral context, developmental and psychosocial history, screening information, examination findings, and the assessment and management plan. It is designed to capture only details explicitly present in the information provided.
Paediatrician
- Psychodynamic Psychotherapy Session NoteA structured follow-up psychotherapy template for documenting presentation, session material, therapeutic process, psychodynamic formulation, risk, interventions, progress, goals, and next steps. It is intended for mental health clinicians using a psychodynamic approach.
Psychologist
- ADHD Diagnostic Outcome And Medication Plan LetterA reusable letter framework for communicating the outcome of an ADHD assessment and the start of medication to primary care and the patient. It covers diagnostic findings, presentation, relevant history, treatment choices, prescribing, monitoring, safety advice, follow-up, and crisis information.
Psychiatrist
- Fibromyalgia and Chronic PainA structured template for documenting a comprehensive assessment of widespread chronic pain and fibromyalgia. It covers symptoms, relevant history, examination, diagnostic criteria, investigations, treatment planning, and follow-up.
Family Medicine Specialist
- SOAPIERA structured physiotherapy documentation template for recording subjective concerns, objective findings, assessment, treatment, evaluation, and follow-up. It supports comprehensive visit documentation, progress tracking, and planning of ongoing care.
Physiotherapist
- ADHD Review TemplateA structured template for documenting follow-up reviews of ADHD treatment. It covers medication use and response, current symptoms, adverse effects, physical monitoring, investigations, risk, mental state examination, and the treatment plan.
Psychiatrist
- Psychology Session NoteA concise structure for documenting psychology and therapy sessions. It covers updates since the previous session, background information, current presentation, session content, interventions, tasks between sessions, planning, risk, and a session summary.
Psychologist
- ED General NoteA structured Emergency Department template for documenting the presenting complaint, relevant history, examination, investigations, reassessment, procedures, and disposition planning. It is intended to support detailed, accurate encounter documentation using only explicitly provided clinical information.
Emergency Medicine Specialist
- Aesthetic Consultation FormThis template is used to document consultations for aesthetic treatments. It covers patient and consultation details, aesthetic concerns, examination findings, the proposed treatment plan, consent, and clinician information.
General Practitioner
- Play Therapy NoteThis template structures documentation of therapeutic play sessions with children. It captures the session presentation, play activities and symbolic themes, treatment response, progress, goals, and follow-up planning.
Psychiatrist
- Young Person’s Biopsychosocial Mental Health AssessmentA structured template for documenting a young person’s comprehensive mental health assessment, including referral context, biopsychosocial formulation, mental state examination, outcome measures, safety, goals and treatment planning. It supports an integrated review of clinical presentation, functioning, risk, protective factors and proposed care.
Mental Health Counselor
- Autism Assessment ReportA reusable template for documenting comprehensive autism assessments, including developmental, medical, behavioural, educational and family information. It also covers social communication differences, restricted and repetitive behaviours, and Autism Quotient scoring.
Speech Pathologists
- Psychiatric Assessment ReportA structured template for documenting a comprehensive psychiatric evaluation, including diagnoses, medications, investigations, background, mental state, risk, formulation, treatment, and safety planning. It is designed to support thorough clinical records using only explicitly provided information.
Psychiatrist
- Appraisal DocumentationA structured template for recording staff performance appraisals in a healthcare setting. It covers prior objectives, current performance, development needs, career planning, upcoming objectives, and agreed responsibilities.
Practice Manager
- Osteoporosis ConsultA consultation template for documenting a comprehensive osteoporosis assessment, including medical and fracture history, medications, risk factors, examination findings, investigations, risk scoring, and a management plan.
Rheumatologist
- Weight LossThis template supports holistic documentation of consultations focused on weight management. It covers the patient's presenting concerns, relevant history, virtual examination findings, assessment, and individualized treatment planning, including lifestyle recommendations.
Alternative medicine practitioner
- Cardiac Follow-UpA structured template for documenting cardiology follow-up visits, including diagnoses, investigation results, medication therapy, symptoms, risk factors, examination findings, recommendations, and follow-up planning.
Cardiologist
- Respiratory Clinic LetterA reusable letter structure for respiratory specialists to communicate a patient's primary respiratory diagnosis, clinical background, examination findings, investigations, and management recommendations to other healthcare professionals or caregivers. It also includes recipient, patient-identification, sign-off, and copy-recipient details.
Respiratory Physician
- Problem-Based Primary Care NoteA structured template for documenting primary care visits by individual problem, issue, or request. It covers the history of present illness, relevant review of systems, physical examination, and an assessment and plan for each concern.
Family Medicine Specialist
- Patient Consultation SummaryA patient-friendly template for summarising the main issues discussed, explicitly stated diagnoses, management plans and patient tasks from a general practice consultation. It supports clear communication about treatment and follow-up without using medical abbreviations or jargon.
General Practitioner
- SOAP DetailedA comprehensive SOAP documentation template for recording detailed patient encounters, including subjective history, review of systems, objective findings, assessments, issue-specific evaluations and plans, and follow-up. It is suited to complex visits, chronic conditions, and encounters involving multiple concerns.
Nurse Practitioner
- Bilan De Kinésithérapie Et Plan De SoinsModèle structuré pour documenter les séances de kinésithérapie, depuis les informations du patient et ses antécédents jusqu’à l’examen, au traitement, à l’évaluation et au plan de prise en charge.
Physiotherapist
- Naturopath ConsultThis template supports comprehensive naturopathic consultations by organizing symptoms and concerns across major health domains, along with sleep, diet, exercise, treatment priorities, and interventions. It is intended to provide a structured overview for individualized naturopathic care planning.
Naturopath
- Well Child CheckA reusable template for documenting routine infant and child health assessments, including history, growth, nutrition, development, examination, screening, immunizations, and follow-up planning. It supports structured recording of caregiver concerns and preventive guidance during well-child visits.
General Practitioner
- Abnormal Uterine BleedingA reusable template for comprehensively documenting abnormal uterine bleeding in general practice. It covers the presenting history, relevant medical and family history, menstrual and reproductive screening, examination, investigations, and explicitly stated assessment and management plans.
General Practitioner
- Medicolegal ReportA structured template for preparing comprehensive medical reports for legal purposes. It covers patient and referral details, the report’s purpose, clinical history, examination, investigations, diagnosis, professional opinion, recommendations, conclusion, and clinician sign-off.
General Practitioner
- Dental Extraction DocumentationA reusable template for documenting dental extractions from pre-operative assessment through post-extraction care. It covers history, tooth findings, anaesthesia, extraction technique, complications, haemostasis, instructions, medications, follow-up, and provider details.
Dentist
- Diabetes Check-upA reusable template for documenting diabetes-focused consultations, including patient details, diabetes and family history, medicines, measurements, examination findings, investigations, and follow-up planning. It supports consistent recording of treatment decisions and ongoing diabetes monitoring.
General Practitioner
- Hospitalist DischargeA structured template for documenting a patient's hospital admission and discharge, including the presenting illness, relevant medical history, diagnoses, hospital course, medications, and discharge plan. It supports concise communication and continuity of care after hospitalization.
Family Medicine Specialist
- Nursing Vital Signs And Systems Assessment TemplateA concise nursing assessment template for documenting measured vital signs and structured findings across the HEENT, respiratory, cardiac, abdominal, musculoskeletal, and skin systems. It supports clear, objective head-to-toe clinical documentation without adding unobserved findings.
Nurse
- Comprehensive Adult ADHD Evaluation TemplateThis template supports comprehensive initial ADHD assessments for adults. It covers identifying information, mental state examination, developmental and psychosocial history, ADHD symptoms, functional impairment, and diagnostic impressions.
Psychiatrist
- Comprehensive Geriatric AssessmentA structured template for documenting a multidimensional geriatric evaluation, including cognition, mood, mobility, medical and functional history, social context, examination, investigations, impression, and care planning. It supports consistent assessment of older adults and associated geriatric syndromes.
Geriatrician
- Dental Emergency ExamA reusable template for documenting urgent dental presentations, including the complaint, relevant dental and medical history, extra-oral and intra-oral findings, investigations, diagnoses, prognosis, and treatment planning.
Dentist
- Developmental consultationA structured template for documenting a child’s developmental consultation, including presenting concerns, developmental and medical history, family and social context, examination, assessment, and plan. It supports a comprehensive record of developmental strengths, difficulties, investigations, and recommended follow-up.
Paediatrician
- Paediatric Sleep HistoryA structured template for documenting a child’s sleep schedule, environment, habits, symptoms, behaviours, and sleep quality. It also captures relevant investigations, medications, medical, family, and social history to support assessment of sleep-related conditions.
Paediatric Neurologist
- Developmental Delay ToddlerA structured paediatric template for evaluating developmental concerns in a young child. It covers developmental domains, relevant history, examination and behaviour, investigations, and the assessment and care plan.
Paediatrician
- Gastroenterology Follow-Up NoteA structured gastroenterology follow-up template for documenting presenting concerns, relevant history, examination findings, gastrointestinal assessments, and condition-specific management plans. It also captures investigations, treatments, lifestyle guidance, referrals, and follow-up instructions for complex GI care.
Gastroenterologist
- Operative NoteThis template is for documenting urologic surgical procedures, including diagnoses, procedural details, personnel, anesthesia, fluids, blood loss, drains, complications, specimens, indications, and the postoperative plan. It supports complete operative documentation for patient care and legal records.
Urologist
- Cardiology Follow-UpA reusable template for documenting cardiology follow-up encounters. It organizes background, medications, symptoms, examination, investigations, and the impression and plan, including management and follow-up details.
Cardiologist
- Work Excuse LetterA reusable letter for documenting a patient’s medically advised absence from work or school. It captures the relevant care period, diagnosis, leave dates, expected return date, and clinician details for formal communication.
Nurse Practitioner
- General Clinical Intake TemplateA standard template for general clinical intake and patient assessment.
Mental Health Social Work
- GIM Ward Round TemplateFor daily ward rounds
Internal Medicine Specialist