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 4 of 13
- Weight Management Progress NoteA reusable template for documenting progress in weight management, including subjective concerns, dietary and exercise habits, objective findings, assessment, barriers, and the ongoing care plan.
Nurse Practitioner
- PEC - AdmissionThis template is for documenting an emergency department admission, including the presentation, history, examination, investigations, assessment, emergency treatment and ongoing plan. It supports structured capture of clinically relevant details while preserving explicit inclusion and formatting rules.
Emergency Medicine Specialist
- Psychology Progress NoteA structured template for documenting psychology sessions, including presenting concerns, functioning, mental status, risk, clinical formulation, interventions, treatment planning, and follow-up. It supports both standard therapy documentation and sessions involving CCS Recovery Plans.
Psychologist
- Minor Surgical ProcedureA reusable template for documenting minor surgical procedures, including patient details, indications, pre-operative assessment, procedural findings, specimen handling, post-operative care, education, and follow-up.
General Practitioner
- GP Chronic Condition Management PlanA structured template for documenting eligibility, consent, chronic conditions, goals, treatments, patient responsibilities, care coordination, and review arrangements in a GP Chronic Condition Management Plan.
General Practitioner
- Initial oncology consultationA structured template for documenting a patient's first oncology assessment, including the referral context, presenting concerns, investigations, medical history, medications, social history, examination, and impression. It supports a comprehensive and clearly organized evaluation for cancer management.
Medical Oncologist
- Trauma-Focused ACT Therapy Session NoteThis template structures documentation for trauma-focused Acceptance and Commitment Therapy sessions. It covers the presenting concerns, all six ACT Hexaflex processes, additional interventions or home practice, and therapist reflections or next steps.
Psychologist
- Ophthalmology Consult NoteA reusable template for documenting comprehensive ophthalmology consultations. It covers subjective ocular and medical history, objective eye examination findings, assessment, treatment planning, follow-up, education, and referrals.
Ophthalmologist
- Rheumatology Review LetterA structured letter template for documenting a rheumatology review, including diagnosis history, medicines, progress, examination, investigations, management, and follow-up arrangements. It also captures relevant education, symptom-monitoring guidance, and concerns discussed with the patient or family.
Rheumatologist
- Medical CertificateA reusable medical certificate structure for documenting examination details, recommended leave, fitness to return to work or usual activities, provider information, and consent-based disclosures. It is intended for official employment, insurance, or related verification purposes while limiting clinical detail to information explicitly provided and authorised.
General Practitioner
- Psychology Discharge SummaryA structured template for documenting the completion of psychological therapy, including referral details, presenting concerns, diagnosis, treatment, progress, observations, risk, outcomes, discharge planning, and recommendations.
Psychologist
- Comprehensive Geriatric Assessment NoteA structured template for documenting a comprehensive geriatric assessment, including medical history, medications, allergies, psychosocial circumstances, functional abilities, systems review, examination findings, cognition, consultation issues, and recommendations.
Geriatric Medicine Specialist
- General Dental Assessment TemplateA structured template for documenting comprehensive dental examinations, including medical and social history, presenting concerns, clinical findings, imaging, diagnoses, treatment discussions, and follow-up care.
Dentist
- GP Multi-Issue Consultation TemplateA structured template for documenting general practice consultations, covering presenting issues, relevant history, examination, clinical impressions and management. It supports concise, organised recording of multiple concerns while preserving clinically relevant details and follow-up actions.
General Practitioner
- Paediatric Preventive Health Visit NoteA reusable template for documenting routine paediatric health visits, covering history, examination, development, prevention, immunisations, follow-up, and education. It is intended to support complete, structured documentation of a child’s ongoing health and development.
General Practitioner
- DBT Treatment PlanA structured template for documenting Dialectical Behaviour Therapy treatment plans, including diagnosis, presenting concerns, goals, measurable objectives, interventions, discharge planning, and treatment frequency.
Counselors
- Psychiatric Assessment Update for GPA reusable English letter structure for psychiatrists communicating patient assessments, relevant history, diagnostic impressions, and management plans to a General Practitioner. It covers presenting concerns, mental state, substance use, psychosocial background, medications, and follow-up.
Psychiatrist
- Complete Physical ExamA reusable template for documenting a comprehensive health assessment, including medical concerns, preventive screening, cardiovascular risk factors, examination findings, and management plans. It is suitable for routine physicals and ongoing preventive care.
General Practitioner
- Sports Physical TemplateA reusable template for documenting pre-participation sports examinations, including medical and family history, physical and musculoskeletal findings, and participation clearance. It supports consistent identification of health concerns relevant to athletic activity.
Sports physician
- Consultant ReferralA referral letter template for osteopaths to share a patient's history, examination findings, investigations, clinical impression, and management plan with another healthcare professional. It supports clear communication about musculoskeletal presentations such as persistent pain or restricted mobility.
Osteopath
- Primary Care Visit NoteA structured template for general practitioners to document patient visits, including history, examination findings, investigations, and issue-based assessment and planning. It supports consistent recording of clinical concerns, relevant background, and explicitly documented management decisions.
General Practitioner
- Osteopathic Return VisitA reusable template for documenting follow-up osteopathic visits, including the patient’s reported symptoms, examination findings, working diagnosis, treatment plan, interventions, response, and additional guidance. It supports concise, structured tracking of progress and ongoing care.
Osteopath
- Occupational Therapy Functional Profile AssessmentA reusable occupational therapy assessment structure covering health history, cognition, communication, behaviour, sensory function, mobility, daily activities, home environment, supports, and therapy goals. It is intended to document an initial functional profile and guide individualized occupational therapy planning.
Occupational Therapist
- Comprehensive Psychiatric IntakeA reusable template for documenting a comprehensive initial psychiatric evaluation. It covers presenting concerns, psychiatric and medical history, medications, psychosocial context, risk, mental status, diagnostic formulation, and the assessment and plan.
Psychiatrist
- Psychodynamic Therapy SOAP NoteThis bulleted SOAP note structure is intended for psychologists working with psychodynamic or object-relations approaches. It organizes documentation of family and relationship dynamics, emotional processing, intimacy and boundaries, observations, clinical formulation, progress, and next-step interventions.
Psychologist
- Autism DiagnosisA structured template for documenting paediatric autism assessments, including patient details, developmental and medical history, observed behaviour, diagnostic conclusions, recommendations, follow-up, and clinician details.
Paediatrician
- Generic Referral - EMISA reusable referral letter structure for dentists referring a patient to a specialist. It captures the referral urgency, clinical concern, relevant history, examination, investigations, diagnosis, management to date, and the specialist input requested.
Dentist
- SP Progress NoteA reusable speech therapy progress note structure for documenting session observations, goals, caregiver reports, activities, recommendations, and follow-up planning. It supports consistent tracking of articulation, language, and other communication-related progress without adding information that was not provided.
Speech Pathologist
- ArztbriefDiese Vorlage strukturiert die Weitergabe medizinischer Informationen an weiterbehandelnde Ärzt:innen. Sie umfasst den Vorstellungsgrund, Patientendaten und Diagnosen, den Behandlungsverlauf, die Entlassmedikation sowie Empfehlungen für die weitere Versorgung.
General Practitioner
- Lab Review NoteA reusable template for documenting and interpreting laboratory findings, including abnormalities, trends, comparisons, clinical assessment, and management planning. It supports decisions about treatment, follow-up testing, medication changes, and patient counseling based on the information provided.
Family Medicine Specialist
- Comprehensive Chronic Care Management NotesA structured template for documenting chronic care management for patients with multiple ongoing conditions. It covers patient details, care needs, consent, coordination, transitions, time tracking, and billing documentation.
Nurse
- Men’s Medicare Annual Wellness AssessmentA reusable template for documenting an annual Medicare wellness visit for a male patient. It covers patient and visit details, health risks, medical history, preventive care, assessment and planning, counseling, and advance care planning.
Sports physician
- Prolapse/Incontinence (Gynecology)This template structures gynecological consultations concerning urinary incontinence and pelvic organ prolapse. It covers presenting concerns, relevant medical, gynecological, obstetrical and social history, examination, investigations, assessment and management planning.
Obstetrician & Gynaecologist
- Therapy NoteA reusable therapy-session documentation template for recording the patient’s presentation, concerns, progress, therapeutic topics and interventions. It also covers medications, safety assessment, follow-up communication, billing codes, and care-plan tasks.
Psychiatrist
- Pediatrician's noteA reusable paediatric visit template covering demographics, subjective history, examination findings, growth and development, investigations, assessment, treatment planning, referrals, and billing. It is suitable for routine child health visits and common paediatric concerns while retaining structured documentation of immunizations and developmental status.
Paediatrician
- MigraineA clinical documentation template for recording migraine-related history, examination findings, investigations, treatment history, impression, and management recommendations. It is structured for concise communication with the referring GP and other healthcare professionals.
Neurologist
- ED NoteA structured template for documenting Emergency Department assessments from presentation through management and disposition. It covers the presenting complaint, clinical history, ABCDE examination, investigations, impression, plan, family discussion, and clinician details.
Emergency Medicine Doctor
- Case Formulation [4Ps]This template supports comprehensive mental health case formulations using the 4Ps framework. It covers the client’s goals, presenting problems, contributing and maintaining factors, protective factors, problem and treatment goals, formulation, and planned interventions.
Psychologist
- Meeting MinutesThis template is for recording clinical meeting details, including logistics, participants, agenda items, discussion points, decisions, assigned actions, and plans for the next meeting.
Psychologist
- BIRP NoteA reusable BIRP note structure for documenting therapy sessions, covering the patient's behavior, interventions delivered, response to treatment, and future care plan.
Marriage and family therapist
- Ward RoundA structured template for gastroenterology ward-round documentation. It covers presenting complaints, diagnoses, subjective and objective findings, assessment, prophylaxis and treatment considerations, lifestyle advice, discharge planning, and follow-up.
Gastroenterologist
- Pediatric Preventive Care Visit NoteA structured template for documenting routine pediatric well-child visits. It covers the presenting concern, history, growth and vital signs, development, diet, review of systems, examination, screening, immunizations, anticipatory guidance, specialist involvement, assessment and plan, and follow-up.
Family Medicine Specialist
- Orthotics AssessmentA structured template for podiatrists to document comprehensive assessments of foot, ankle, and lower-extremity concerns. It covers subjective history, examination findings, diagnoses, orthotic considerations, treatment, education, and follow-up.
Podiatrist
- GP Consultation TemplateA structured template for documenting primary care consultations, including the consultation context, consent, history, investigations, examination findings, diagnoses and management plan. It supports concise, comprehensive records while retaining explicit-only documentation rules.
Nurse Practitioner
- Oncology Clinic NoteA comprehensive oncology follow-up template for documenting the patient’s cancer history, current concerns, examination findings, investigations, treatment, assessment, and follow-up plan. It is structured for concise, evidence-based clinical progress notes using only information explicitly provided.
Oncologist
- Primary Care Consultation NoteThis template supports structured documentation of primary care consultations, including the presenting history, relevant investigations, examination findings, diagnoses, and management plan. It is suitable for documenting face-to-face and telephone consultations while preserving only information explicitly provided.
General Practitioner
- Travel Vaccination RecommendationsA structured template for documenting travel-health consultations in primary care. It covers the itinerary, relevant medical history, vaccination status, destination-specific vaccine and malaria advice, yellow fever considerations, general travel guidance, and follow-up.
General Practitioner
- EMDR Therapy Session Progress NoteA structured template for documenting EMDR therapy sessions, including the target memory, cognitions, emotions, body sensations, processing, installation, body scan, closure, and future treatment considerations.
Therapist