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 3 of 13
- General ConsultA reusable template for osteopaths to document comprehensive consultations, including subjective and objective findings, osteopathic assessment, treatment planning, interventions, progress evaluation, education, and home care.
Osteopath
- Breast Surgeon NoteThis template supports breast surgeons in documenting consultations involving breast masses, prior operations, cancer family history, and other surgical concerns. It organizes the relevant history, examination findings, assessment, treatment planning, education, and follow-up needs.
Breast Surgeon
- Well Adolescent (AWJ)A structured template for routine adolescent well visits, covering medical history, nutrition, activity, education, home circumstances, confidential risk and wellbeing topics, examination findings, and follow-up planning. It supports a comprehensive review of physical, emotional, social, and developmental health.
Paediatrician
- Cardiac Arrest ScribeA structured template for documenting cardiac arrest recognition, resuscitation interventions, team communication, patient response, and final outcome. It supports comprehensive recording of emergency care in emergency department and critical care settings.
Emergency Medicine Specialist
- Sports Medicine Acute Injury Assessment NoteA structured template for sports medicine clinicians documenting acute presentations and injuries. It covers the presenting concern, symptom history, focused review of systems, examination, clinical assessment, management, and follow-up.
Sports physician
- Neurology Follow-Up Clinic LetterA patient-facing template for neurology follow-up letters. It organises diagnoses, medicines, clinical history, examination findings, investigations, differential diagnoses and management steps in clear language.
Neurologist
- Orthopaedic Consultation Update for GPA structured letter template for orthopaedic surgeons to update a general practitioner about a patient's presentation, relevant history, examination, investigations, and management. It supports clear communication about musculoskeletal conditions, surgery, ongoing treatment, and follow-up needs.
Orthopaedic Surgeon
- Pediatric Routine Dental Examination NoteThis template is for documenting routine dental examinations for children, including attendance details, medical and dental history, examination findings, risk assessments, treatment discussions, consent, radiographs, and follow-up planning. It supports comprehensive recording of preventive, restorative, and orthodontic care.
Dentist
- Menopause Health AssessmentA structured template for assessing menopausal symptoms, relevant history, examination findings, investigations, referrals, and agreed management. It supports concise, comprehensive documentation of the patient’s concerns and treatment preferences.
General Practitioner
- Emergency Department NoteA reusable emergency medicine documentation structure for acute presentations. It captures the presenting complaint, medical history, symptom-focused review, examination, assessment, plan, and reassessment updates.
Emergency Medicine Specialist
- Nursing Care Plan NotesA structured template for documenting two nursing diagnoses, including supporting assessment data, related factors, defining characteristics, goals, expected outcomes, interventions, rationales, evaluations, and any needed revisions.
Nurse
- Occupational Therapist Summary and RecommendationsA structured template for occupational therapists to record a client's functional assessment across social, medical, mobility, personal care, domestic, community, and cognitive domains. It also captures primary concerns, recommended equipment and home modifications, referral consent, and the planned actions.
Occupational Therapist
- Standard Operative NoteA structured template for documenting a surgical procedure, including its indication, operative team, anaesthesia, positioning, procedural steps, findings, complications, closure, and postoperative care. It is designed to capture only details explicitly stated in the information provided.
Surgeon
- GP Comprehensive Medication AssessmentA structured template for documenting a comprehensive medication review, including current medicines, adherence, effectiveness, adverse effects, patient concerns, recommendations, and follow-up.
General Practitioner
- Prosthodontic Consultation Summary LetterA structured letter for prosthodontists to send after a dental consultation. It summarizes the patient's concerns, relevant dental history, examination findings, investigations, proposed prosthetic treatment, advice, medications, and follow-up arrangements.
Prosthodontist
- Holistic Palliative Care Wellbeing AssessmentA holistic assessment template for documenting wellbeing across physical, mental and emotional, family and social, and spiritual dimensions. It supports comprehensive care planning by capturing explicitly stated information about each area of a person's wellbeing.
Palliative Care Physician
- HEADSS assessmentThis template structures a mental health HEADSS assessment for adolescents. It covers home life, education and employment, activities, substance use, sexuality, depression or suicide risk, and safety concerns.
Mental Health Counselor
- PCL-5This template structures the assessment of PTSD-related symptoms using the PCL-5 response scale. It covers trauma-related memories, avoidance, mood and cognition changes, arousal, reactivity, and sleep, while recording only explicitly provided or selected information.
Psychiatrist
- NDIS Physiotherapy Initial AssessmentA structured template for documenting an initial NDIS physiotherapy assessment. It covers participant information, diagnoses, medical and social history, mobility and communication, pain, equipment, subjective and objective findings, goals, clinical impressions, and the proposed plan.
Physiotherapist
- Initial ConsultationA reusable template for documenting a psychologist’s comprehensive first-session assessment. It covers presentation, presenting concerns, interventions, background, medical and developmental history, risk, goals, and follow-up plans.
Psychologist
- Psychiatric ConsultationThis template structures a comprehensive psychiatric assessment, covering patient identification, presenting illness, psychiatric and medical history, medications, substance use, family and legal history, mental status examination, and impressions with recommendations.
Psychiatrist
- Health Assessment 75+A comprehensive template for documenting the health, lifestyle, support needs, preventive care, and functional status of patients aged 75 years and older. It covers family and social history, services, recreation, substance use, immunisations, medications, mobility, nutrition, exercise, sleep, sensory health, activities of daily living, driving, and skin checks.
Nurse
- PHQ-9A structured template for administering and documenting the PHQ-9 depression questionnaire. It records each symptom score and timing, calculates the total score, assigns a depression severity level, and captures the functional impact of symptoms.
Psychiatrist
- 15 Month Well Child CheckA structured template for documenting a 15-month well child visit, including acute concerns, nutrition, elimination, sleep, dental history, development, examination findings, and an assessment and plan.
Paediatrician
- Chronic Care Management NoteA reusable template for documenting chronic care follow-up, including patient-reported concerns, examination findings, condition-specific assessment and planning, medication use, investigations, referrals, and care coordination.
Family Medicine Specialist
- CPD Consultation ReflectionA reusable template for recording a clinician’s reflections on a patient consultation for continuing professional development. It covers the consultation details, clinical learning, management decisions, reflections, future practice actions and explicitly stated CPD credits.
General Practitioner
- Dermatology LetterA reusable letter template for documenting and communicating a dermatology consultation. It covers the visit reason, relevant history, examination, investigations, diagnosis, and management plan in a patient-directed format.
Dermatologist
- Consultation MG, courriers et imageriesModèle polyvalent pour structurer un courrier médical ou un certificat d’inaptitude sportive à partir des éléments explicitement communiqués. Il rassemble les antécédents pertinents, le contexte clinique, les examens réalisés et la demande adressée au confrère, tout en encadrant les règles de durée et de médicaments.
Family Medicine Specialist
- 4 P'sA structured template for behavior therapists to document client goals, presenting problems, the four categories of contributing factors, identified problems, treatment goals, case formulation, and interventions. It supports organized case conceptualization and treatment planning.
Behaviour Therapist
- Critical Care Daily Review NoteA structured template for documenting an intensive care ward round using the ABCDEFGHIL assessment framework. It covers the patient’s progress, organ-system status, FASTHUGS review, and management plan.
Intensive Care Specialist
- ADI-R SummaryA structured template for documenting an Autism Diagnostic Interview–Revised assessment. It organises caregiver-reported developmental, communication, social, behavioural, sensory, and aggression information, followed by the clinician’s explicitly stated interpretation.
Psychologist
- General Psychiatry New Patient AssessmentA reusable template for documenting an initial community-based psychiatry assessment in UK English. It covers medication and care planning, presenting concerns, psychiatric and medical history, substance use, family and personal history, mental state examination, discussion, and physical health parameters.
Psychiatrist
- School-Based Pediatric OT AssessmentThis template supports an occupational therapist’s school-based initial assessment of a child’s functional performance. It covers referral context, current abilities, self-care, motor, self-management, classroom, social, play, communication, areas of OT focus, and therapy goals.
Occupational Therapist
- Psychotherapy Progress NoteA reusable template for documenting psychotherapy sessions, including the patient’s presentation, interventions, progress, and response to treatment. It supports concise tracking of mental health concerns, therapeutic changes, ongoing difficulties, and future areas of focus.
Psychotherapist
- Progress LetterA physiotherapy correspondence template for updating a referring doctor on a patient’s assessment, treatment, response, and ongoing plan. It covers patient details, objective and radiological findings, treatment delivered, progress, and requests for clinical input.
Physiotherapist
- Informed Consent DocumentationThis template documents the informed consent discussion for proposed healthcare, including the treatment, risks and benefits, patient responses, alternatives, resources, and consent details. It also captures additional considerations such as refusal or withdrawal of care, competency, and communication barriers.
General Practitioner
- GP NoteA structured template for documenting general practice consultations, including presenting problems, examination findings, assessments, and plans. It supports concise recording of multiple issues while retaining relevant clinical history and management details.
General Practitioner
- Narrative Intake SummaryThis template provides a structured narrative for documenting an initial clinical intake, including presenting concerns, medical and social history, medications, allergies, family history, review of systems, examination findings, diagnostic results, treatment, and follow-up advice. It is intended to support comprehensive documentation using only information explicitly provided.
Cognitive Behavioral Therapist
- Dietitian Follow-upA structured template for documenting a dietitian follow-up visit, including the patient's progress, obstacles, nutrition-related updates, interventions, education, dietary recall, next steps, and a patient-facing recap.
Dietitian
- Basic Dental Consultation NotesA structured template for documenting dental consultations, including the presenting reason, relevant medical and dental history, clinical and radiographic findings, diagnostic tests, diagnoses, treatment planning, referrals, discussed risks, and quoted fees.
Dentist
- Comprehensive Dental ExaminationA structured template for recording a detailed dental examination, including practitioner and patient history, extra-oral and intra-oral findings, investigations, diagnoses, discussions, treatment, consent, and follow-up. It supports comprehensive documentation of routine examinations and specific dental concerns.
Dentist
- Trauma NoteA structured Emergency Medicine template for documenting trauma presentations. It covers the mechanism of injury, prehospital course, primary and secondary surveys, resuscitation, investigations, procedures, reassessments, injuries, and disposition planning.
Emergency Medicine Specialist
- Midwife Antenatal AssessmentA reusable template for documenting midwifery antenatal appointments. It covers the initial assessment, physical findings, results, medications, emotional and social wellbeing, preparation for the baby, education, referrals, birth preferences, and follow-up planning.
Midwife
- ENT Consultation LetterA structured letter template for documenting otorhinolaryngology consultations. It covers the presenting problem, relevant histories, examination and investigation findings, clinical impression, management plan, procedure-specific risks, and correspondence recipients.
Otorhinolaryngologist (ENT Specialist)
- Surgical ReviewA reusable template for documenting surgical consultations, including patient details, presenting concerns, relevant history, examination findings, investigations, clinical impression, and management plans. It supports structured pre-operative assessments and post-operative follow-up documentation.
General Surgeon
- ADD Risk StrategyA reusable structure for documenting an Autism Spectrum Disorder (ASD) assessment, including mental health, social context, ASD-related observations, family history, risk, and follow-up planning.
Mental Health Nurse
- TF-CBT EncounterA structured template for documenting trauma-focused cognitive behavioral therapy sessions. It captures the interventions used, the patient’s engagement and responses, observed progress, and application of treatment strategies in daily life.
Clinical Social Worker
- BIRPA structured mental health documentation template for recording behavior, therapeutic interventions, responses, and plans. It also captures the client’s stage of change to support monitoring of progress and ongoing treatment.
Mental Health Counselor