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 2 of 13
- Two-Patient Multi-Issue Visit NoteThis template structures documentation for visits involving two patients, each with two separate issues. It captures subjective information, objective findings, assessment, and plan details for every issue.
Family Medicine Specialist
- Medical Transfer NoteA structured template for documenting the transfer of inpatient medical care between healthcare facilities. It covers the clinical course, recent updates, review of systems, examination findings, assessment and plan, safety measures, and disposition.
Internal Medicine Specialist
- Cardiology Follow-Up Consultation NoteA structured template for concise cardiology follow-up correspondence, covering the patient’s history, social and family context, medications, symptoms, examination, investigations, assessment, management, and follow-up.
Cardiologist
- DAPA structured template for documenting therapy sessions using the Data, Assessment, and Plan format. It captures client and provider details, session information, clinical observations, treatment progress, interventions, follow-up planning, and coding and billing information.
Therapist
- Preventive Care – Scale and Clean, Fluoride, SealantsThis template supports documentation of routine preventive dental visits involving scaling and cleaning, fluoride treatment, and fissure sealants. It covers relevant history, oral hygiene, examination findings, periodontal assessment, treatment provided, advice, patient response, and follow-up planning.
Dentist
- Wound Assessment and Care Planning TemplateA structured template for documenting comprehensive wound evaluations and individualized care plans. It covers patient information, wound and nutrition assessments, treatments, education, referrals, therapeutic goals, and follow-up evaluation.
Nurse Practitioner
- Follow-up AppointmentThis template is for documenting a psychology follow-up appointment, including changes since the previous session, current subjective and objective findings, assessment, and planned care. It supports structured tracking of symptoms, investigations, diagnoses, treatment, and referrals.
Psychologist
- Clinical Intake AssessmentA reusable template for documenting an initial counselling or mental health assessment. It covers presenting concerns, history, coping and protective factors, trauma, risk, outcome measures, recommendations, goals, and treatment planning.
Counselling Psychologist
- Acupuncture Visit SOAP NoteA reusable SOAP note structure for documenting acupuncture visits, including the patient's reported experience, examination findings, assessment, treatment plan, acupuncture details, additional modalities, recommendations, referrals, and follow-up.
Acupuncturist
- SOAP List IssuesA structured SOAP template for documenting multiple patient concerns in family medicine. It organizes subjective information, relevant history, objective findings, and issue-specific assessments and plans.
Family Medicine Specialist
- Gastroenterology NoteThis template structures gastroenterology visit documentation, including presenting symptoms, relevant history, medications, examination findings, assessment, treatment planning, and follow-up. It is intended for recording gastrointestinal conditions and organizing condition-specific investigations and management.
Gastroenterologist
- Diagnostic Formulation TemplateA structured template for documenting psychological diagnostic formulation, including referral concerns, diagnostic considerations, the 4P model, functional effects, risk, and recommendations in the South African context.
Psychologist
- Internal Medicine New Consultation NoteA structured template for documenting an internal medicine new-patient consultation. It covers the referral reason, presenting illness, medical and family history, medications, examination, investigations, summary, and plan.
Internal Medicine Specialist
- Nephrology Follow-Up Clinic LetterA reusable English template for documenting nephrology outpatient follow-up consultations. It covers the consultation summary, examination and investigation findings, renal assessment and management plan, medications, education, and follow-up arrangements.
Nephrologist
- Inpatient Progress NoteA reusable structure for concise inpatient psychiatric progress documentation. It covers admission background, clinical progress, record review, mental state, physical findings, risk, impression, and ongoing care planning.
Psychiatrist
- Healthcare Team Meeting NotesA reusable template for documenting healthcare team meetings, including meeting details, participants, discussion items, referenced materials, and assigned actions.
Physician
- UK History TemplateA structured template for documenting a UK primary-care history, examination findings, diagnoses, and management plan. It covers presenting concerns, relevant background, medicines, social history, allergies, system examinations, diagnostic assessments, treatment, follow-up, education, and investigations.
General Practitioner
- Child and Adolescent IntakeA structured intake template for documenting a child or adolescent’s mental health presentation, family context, developmental and medical background, education, behaviour, and emotional well-being. It also includes consent and confidentiality documentation.
Psychologist
- Urology Follow-Up for Elevated PSAA structured template for documenting urology follow-up visits involving elevated PSA. It covers the relevant history, PSA progression, biopsy and symptom information, examination, assessment, management, counseling, orders, and follow-up.
Urologist
- Chiropractic Initial ConsultationA structured template for documenting an initial chiropractic consultation, including referral details, history, symptom assessment, examination, investigations, clinical impression, and management planning. It supports comprehensive capture of explicitly documented patient information without adding unstated details.
Chiropractor
- Dental TraumaA structured template for documenting dental trauma, including patient and incident details, relevant medical history, examination findings, diagnostic tests, emergency treatment, post-operative advice, prognosis, and follow-up planning. It supports comprehensive and consistent recording of dental injuries and their management.
Dentist
- Hospitalist Progress NoteA structured template for documenting the daily inpatient course, current findings, issue-based assessment and plan, and discharge-related care details. It supports concise communication among hospital medicine and other inpatient teams.
Internal Medicine Specialist
- GP Specialist Advice Request LetterA reusable letter structure for requesting specialist advice about a patient. It captures the sender and recipient details, the patient’s presentation and relevant history, clinical findings, current management, and the specific guidance being requested.
General Practitioner
- GP LetterA reusable letter structure for rheumatologists communicating referral outcomes, diagnoses, investigations, treatment decisions, and follow-up plans to general practitioners. It also includes a concise consultation summary for documenting explicitly stated clinical information.
Rheumatologist
- Psychology Session Progress NoteA structured template for documenting psychology sessions, including the patient’s progress, risk information, therapeutic interventions, and movement toward treatment goals. It also provides space to record the next appointment and any homework assigned.
Psychologist
- Psychiatric Mental Status Assessment TemplateA structured template for documenting a comprehensive Mental State Examination across appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight, and judgment. It supports consistent psychiatric assessments and mental health progress documentation.
Psychiatrist
- CHA2DS2-VASc Score CalculationA structured template for calculating stroke risk in patients with atrial fibrillation or atrial flutter. It captures the relevant clinical factors, score interpretation, anticoagulation planning, follow-up, and documentation details.
General Practitioner
- Comprehensive Psychiatric SOAP with E/M CodingA structured template for documenting child and adolescent psychiatry visits, including presenting concerns, interim history, psychotherapy, medications, mental status examination, assessment, risk, treatment planning, coordination, and E/M coding.
Child and Adolescent Psychiatrist
- Initial Couples Psychiatric Assessment NoteThis template structures an initial couples therapy assessment, covering client and session details, consent, presenting concerns, psychological, biological, and social factors, clinical formulation, mental status, risk, and available strengths and resources.
Psychiatrist
- Detailed Dietitian Initial AssessmentA comprehensive initial assessment template for documenting weight history, body image, eating behaviours, nutritional intake, physical activity, medical history, and lifestyle factors. It also covers disordered eating behaviours, menstrual history, gut health, investigations, medications, and social context.
Dietitian
- MAID Eligibility Assessment TemplateA structured template for documenting a comprehensive Medical Assistance in Dying (MAID) eligibility assessment. It covers identifying information, statutory criteria, applicable assessment tracks, administration options, and detailed clinical history, medications, and allergies.
Family Medicine Specialist
- Bilan initial de kinésithérapieCe modèle structure l’évaluation initiale d’un patient en kinésithérapie, depuis l’histoire de la plainte et les antécédents jusqu’à l’examen clinique, aux objectifs, au traitement, à la conclusion et à la prise en charge. Il convient à la documentation des évaluations, interventions et plans de suivi, en s’appuyant uniquement sur les informations fournies.
Physiotherapist
- Tinnitus ReportA structured template for documenting tinnitus evaluations, including reported symptoms, relevant medical history, audiological test findings, tinnitus education, assessment responses, oral examination, and recommendations.
Audiologist
- Newborn First-Month Wellness Visit NoteA reusable template for documenting routine assessments of neonates from birth through one month of age. It covers birth and feeding history, safety and social context, growth, examination, screening, assessment, anticipatory guidance, and follow-up.
Paediatrician
- Cancer Diagnosis LetterA structured letter for communicating a patient's cancer diagnosis, staging, recommended treatment, and follow-up arrangements. It is designed to support clear, compassionate correspondence from an oncology clinician to a patient.
Orthopaedic Surgeon
- SBAR handoverA structured handover template for communicating a patient's Situation, Background, Assessment, and Recommendations. It supports concise transfer of essential clinical information, including patient identifiers, current concerns, relevant history, findings, and explicitly stated plans.
Internal Medicine Specialist
- Student Medical Leave ConfirmationA structured template for documenting a student's medically required absence from school, including the period of care, reason for absence, and date of return. It is intended to provide educational institutions with a clear confirmation of the student's leave and readiness to resume attendance.
Counselors
- Mounjaro ConsultationA concise documentation framework for consultations involving Mounjaro and other GLP-1 receptor agonists. It captures treatment eligibility, anthropometric details, relevant history, contraindications, pharmacological action, adverse effects, safe use, and follow-up planning.
Acute Medicine Specialist
- ICU Daily NoteA structured daily documentation template for intensive care reviews. It captures the patient’s admission context, progress, system-based examination, current issues, and ongoing management plan.
Anaesthetist
- Psychology Intake Assessment NoteA comprehensive template for documenting an initial psychology assessment. It covers behavioural observations and mental status, relevant personal and family history, presenting concerns, medical and mental health history, psychological measures, diagnostic conceptualization, treatment planning, and follow-up scheduling.
Psychologist
- Behaviour Therapy NoteA structured template for documenting behaviour therapy sessions, including the patient’s reported concerns, observed mental status, clinical assessment, interventions, treatment response, and ongoing care plan. It supports organized tracking of symptoms, goals, risks, and therapeutic progress.
Behaviour Therapist
- GP Consultation Assessment and Plan NoteA structured general practice consultation template for concisely recording the clinical impression and management plan alongside detailed history and examination findings. It is suited to complex consultations and supports clear documentation of clinical decisions and follow-up.
General Practitioner
- Dermatology Consultation Assessment and PlanA concise template for documenting dermatology consultations, including referral details, presenting concerns, history, examination findings, clinical impression, management, counselling, procedures, and follow-up.
Dermatologist
- Root Canal Treatment Procedure NotesA reusable template for documenting root canal treatment, including patient details, medical history, consent, assessment, procedural steps, obturation, post-operative guidance, and follow-up planning.
Dentist
- Autism Diagnostic Observation Schedule – Second Edition Assessment SummaryA reusable structure for documenting observations from an Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) assessment. It covers language and communication, reciprocal social interaction, imagination, stereotyped behaviours and restricted interests, as well as explicitly stated scores and conclusions.
Psychologist
- Exercise Physiology Intake and Goal-SettingThis initial assessment template is for documenting a patient's medical and general background, current activity, sleep, nutrition, hydration, and stressors. It also records goals related to ambulation, strength, pain, falls risk, and community access to support individualised exercise planning.
Exercise Physiologists
- Supervision Session SummaryA reusable template for documenting occupational therapy supervision sessions. It captures discussion topics, reviewed cases, supervisor feedback, agreed follow-up, challenges, professional development needs, and positive outcomes.
Occupational Therapist
- C-SSRS AssessmentA structured template for documenting suicidal ideation, suicidal behavior, self-injurious behavior, preparatory acts, and suicide lethality. It supports consistent assessment of the presence, intensity, timing, and severity of suicide-related thoughts and actions using only explicitly provided information.
Psychiatrist