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 5 of 13
- Specialist Referral LetterA reusable English letter structure for referring a patient from general practice to a specialist. It organizes the referral reason, clinical history, medicines, investigations, contact details, and closing correspondence.
General Practitioner
- GAD-7 Anxiety AssessmentA structured template for documenting the GAD-7 anxiety questionnaire, including patient information, symptom-frequency scores over the previous two weeks, total score, anxiety severity, and the effect of symptoms on daily functioning.
Psychiatrist
- Neurological Consultation and Movement Disorder NoteA structured template for documenting neurological consultations, including presenting concerns, relevant history, medications, examination findings, investigations, diagnostic considerations, and management. It supports detailed recording of movement-disorder features and other neurological issues while limiting entries to information explicitly provided.
Neurologist
- Addiction Medicine Initial Evaluation NoteA structured template for documenting an initial addiction medicine evaluation. It covers identifying information, assessment and risk, diagnoses, treatment planning, medical and psychiatric history, substance use, subjective symptoms, physical findings, and mental status examination.
Addiction Medicine Specialist
- Child Therapy First-Visit Assessment NoteA reusable structure for documenting a child’s initial therapy session, including client information, presenting concerns, psychological, biological, and social factors, clinical assessment, risk, strengths, interventions, progress, goals, and follow-up planning.
Mental Health and Behavioural Specialist
- Chiropractor's noteThis template structures comprehensive chiropractic visit documentation, covering subjective symptoms, objective examination findings, assessment, treatment planning, interventions, and evaluation. It supports consistent tracking of musculoskeletal conditions, spinal care, treatment responses, and ongoing patient progress.
Chiropractor
- GP Comprehensive Clinical OverviewA reusable template for General Practitioners to record a structured overview of a patient's demographics, medical history, current clinical status, diagnostic findings, assessment, care plan, progress, and recommendations. It supports comprehensive case summaries and continuity of care.
General Practitioner
- Home-Based Occupational Therapy Visit NoteA concise structure for documenting occupational therapy home visits. It covers the visit purpose, attendees, subjective and objective findings, professional analysis, interventions, response or progress, and the follow-up plan.
Occupational Therapist
- ADOS-2This template provides a structured framework for documenting communication, social interaction, reciprocity, empathy, imagination, and rapport during an ADOS-2 assessment. It is intended to support detailed clinical evaluation of behaviors relevant to autism assessment.
Psychologist
- Internal Medicine Consultation Summary LetterA structured letter template for sending a detailed medical summary to a referring doctor. It covers patient identifiers, diagnoses, history, examination, investigations, management, outcome, and relevant attachments.
Internal Medicine Specialist
- Medicare Power Scooter ExaminationA structured template for documenting the medical necessity of a power scooter for a patient with mobility limitations. It covers patient and clinical information, functional restrictions, prior interventions, expected benefits, home and caregiver factors, and clinician details for Medicare-related documentation.
Family Medicine Specialist
- Orthopaedic and GP Referral LetterA structured referral letter for physiotherapists to communicate a patient’s presentation, diagnosis, relevant history, treatment to date, and recommended next steps to an orthopaedic clinician or GP.
Physiotherapist
- Dietitian Initial Assessment NoteThis template supports a comprehensive initial dietetic assessment, covering weight history, eating patterns, relevant medical and family history, symptoms, and factors affecting nutrition goals. It also provides a structured format for developing a personalised medical nutrition therapy plan, weight-management targets, and a patient-facing summary of education and action steps.
Dietitian
- Chronic Disease Management PlanA reusable English template for documenting a patient’s eligibility, chronic conditions, assessment, care plan, goals, monitoring, referrals, review, and Medicare billing requirements under Chronic Disease Management services.
Nurse
- Menopause and Perimenopause AssessmentA comprehensive template for documenting consultations about menopause and perimenopause. It covers menopausal stage, relevant history, symptoms, wellbeing, examination findings, investigations, management options, follow-up, preventative health advice, shared decision-making, and documentation.
General Practitioner
- GP Consultation with UK GuidanceA structured template for documenting primary care consultations, including the history, examination, clinical impression, management plan, follow-up, and safety-netting. It also provides a separate area for guideline-informed suggestions based on UK general practice and NICE CKS guidance.
General Practitioner
- Emergency Medicine Initial AssessmentA reusable template for documenting an initial emergency department assessment. It covers the presenting complaint, medical background, current illness, review of systems, examination, investigations, clinical impression, management, and follow-up.
Emergency Medicine Specialist
- Infertility NoteThis template supports documentation of consultations about infertility, covering the presenting concern, relevant medical and lifestyle history, examination findings, diagnostic work-up, assessment, management, and follow-up. It is intended to provide a structured record for infertility evaluation and fertility-care planning.
General Practitioner
- Psychotherapy Process NoteA concise structure for documenting psychotherapy sessions, including the presenting issue, interventions used, the client’s responses, the therapeutic process, and progress toward goals with future planning.
Clinical Psychologist
- Letter of Medical NecessityA reusable letter template for requesting insurer authorization of a medically necessary treatment in Allergy and Immunology. It organizes the patient’s diagnosis, clinical history, prior therapies, treatment rationale, and enclosed supporting records.
Allergy and Immunologist
- Counseling ConsultationA structured template for counselors to document client sessions, including presenting concerns, session discussion, thoughts and insights, obstacles, progress, summaries, and planned next steps. It also provides space to record the timing of the next session when explicitly available.
Counselors
- Person-Centered Encounter NoteA structured template for documenting therapeutic interventions and assessing a patient’s response in a person-centered clinical encounter. It supports recording the therapeutic environment, patient engagement, comfort, transition after the session, and considerations for ongoing care.
Clinical Social Worker
- Child ADHD Diagnostic Assessment TemplateA structured framework for documenting comprehensive ADHD assessments in children. It covers the assessment context, presenting concerns, developmental and psychosocial history, mental state and risk findings, child interview, Young Diva Questionnaire responses, and the discussion and care plan.
Psychiatrist
- Emergency Department Encounter NoteThis emergency department documentation template structures the encounter from presentation and history through examination, investigations, assessment, treatment, and disposition planning. It supports concise capture of clinically relevant information while preserving explicit-information-only documentation rules.
Emergency Medicine Specialist
- Physiotherapy New Patient Evaluation NoteA reusable template for documenting an initial physiotherapy assessment, including the presenting condition, relevant history, goals, objective findings, diagnosis, treatment delivered, clinical assessment, and ongoing plan.
Physiotherapist
- Menopause Consultation Assessment NoteA structured template for documenting consultations involving perimenopausal or menopausal symptoms. It captures presenting concerns, relevant medical and family history, screening, social history, examination findings, treatment decisions, lifestyle guidance, and follow-up.
General Practitioner
- DBT Therapy NoteA structured template for documenting Dialectical Behavior Therapy sessions. It covers the client's subjective presentation, mindfulness and psychoeducation participation, homework, and the clinician's interventions.
Counselors
- Contraceptive HistoryA structured template for documenting contraceptive needs, reproductive and menstrual history, pregnancy risk, and relevant medical, surgical, social, and family history. It supports comprehensive reproductive healthcare assessment using only explicitly provided information.
Family Medicine Specialist
- Patient Summary TemplateA reusable template for condensing a patient’s documented medical history into a focused summary. It captures active problems, prior history, medications, allergies, investigations, treatment, and pending follow-up actions using only the specified source material.
Neurologist
- NHS Nursing Discharge Summary TemplateA reusable NHS discharge summary structure for recording patient identity, admission and discharge details, clinical problems, allergies, medicines, and follow-up arrangements. It supports clear communication of discharge outcomes and ongoing care needs between hospital, patients, families, and community or specialist services.
Nurse
- Medication ReviewA reusable template for pharmacists to document a patient’s medication regimen and review medication-related information. It covers current and newly prescribed medicines, changes, adverse effects, adherence, allergies, monitoring results, education, and follow-up recommendations.
Pharmacist
- Orthopaedic Consultation NoteA structured template for documenting orthopaedic consultations, including the presenting complaint, consultation outcome, age, occupation, relevant medical history, and discussion of treatment and next steps.
Orthopaedics
- Comprehensive Psychiatric AssessmentA structured template for documenting a detailed psychiatric evaluation, including referral context, presenting concerns, psychiatric and medical history, social factors, mental state, risk, clinical formulation, recommendations, and correspondence. It is designed to support complete, efficient documentation using only explicitly provided information.
Psychiatrist
- Inpatient Urology Progress NoteA daily inpatient progress-note template for urologists caring for postoperative patients or patients admitted for non-surgical reasons. It organizes the patient’s interval history, subjective and objective findings, medications, studies, assessment and plan, orders, and signature details.
Urologist
- DIVA/ADHD SummaryA structured template for documenting ADHD inattentive and hyperactive-impulsive symptoms using the client’s own statements. It also captures evidence of symptoms before age 12, functional impact, and differential-diagnosis considerations.
Psychologist
- SOAP physiotherapy sessionA concise SOAP template for physiotherapy documentation. It organises explicitly reported subjective information, objective findings, treatments, assessments, and plans while preserving unfilled sections when required.
Physiotherapist
- COT Performance CriteriaA structured template for assessing and documenting performance across key areas of a general practice consultation. It covers communication, clinical reasoning, examination, management, shared decision-making, follow-up, and resource use for training or assessment.
General Practitioner
- Physio SOAP OutpatientThis template supports outpatient physiotherapy documentation across the patient’s current condition, objective findings, treatment, assessment, and plan. It captures relevant adherence, medication use, symptoms, clinical observations, interventions, goals, progress, and follow-up arrangements.
Physiotherapist
- PAP smear (GP)This template supports general practitioners in documenting cervical screening, including patient and clinical information, procedure details, results, and follow-up. It is intended to promote complete records, continuity of care, and patient education for routine PAP smears.
General Practitioner
- Plastic Surgery Consultation Summary for GPA correspondence template for plastic and reconstructive surgeons to report consultation findings to a General Practitioner. It covers the presenting concerns, relevant history, medications, allergies, social context, clinical assessment, and agreed next steps.
Plastic & Reconstructive Surgeon
- Urgent Care Visit And Restrictions LetterA reusable letter template for documenting an urgent care visit and any associated work or activity excuse. It captures the visit date, reported concerns, clinical findings, relevant history, treatments, recommendations, restrictions, and clinician contact details.
Counselors
- Hearing Aid CheckThis template supports audiologists in documenting routine hearing aid checks, including patient concerns, otoscopy, cerumen management, hearing aid maintenance, adjustments, recommendations, and follow-up planning. It also captures the after-visit summary provided to the patient.
Audiologist
- Psychiatric Ongoing Care Review NoteA structured template for documenting psychiatric follow-up reviews, including changes in history, symptoms, medication response, mental state, risk, capacity, clinical impression, and agreed plans. It supports consistent recording of ongoing care while preserving relevant updates and decisions.
Psychiatrist
- Whole-Person Mental Health AssessmentA structured template for documenting biological, social, and psychological factors relevant to a person’s mental health. It supports a comprehensive assessment by covering presenting concerns, contributing factors, findings, recommendations, and follow-up planning.
Accredited Mental Health Social Worker
- General Paediatrics ConsultationA comprehensive paediatric consultation template for documenting presenting concerns, medical and developmental history, examination findings, investigations, assessment, treatment planning, and disposition. It supports detailed recording of complex clinical, family, educational, and therapy-related information using only explicitly provided details.
Paediatrician
- Initial Dietetic AssessmentA reusable template for diabetes dietitians to record a comprehensive nutritional assessment. It covers patient details, referral information, medical and dietary history, anthropometrics, biochemistry, nutrition-focused examination, psychosocial factors, diagnosis, intervention, and follow-up.
Diabetes Dietitian
- DAP Progress NoteA reusable structure for documenting psychotherapy or mental health sessions using the Data, Assessment, and Plan format. It covers presenting concerns, mental status, interventions, responses, treatment progress, risk documentation, and next steps.
Psychiatrist
- Functional Capacity ReportA reusable report structure for documenting a patient's functional capacity, medical history, objective findings, recommendations, and prognosis. It supports evaluation of daily activities, mobility, cognitive and psychological status, and work-related abilities.
Occupational Therapist