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 6 of 13
- Progress NotesA reusable mental health progress-note structure for documenting patient identity, history, presentation, mental state, social and functional status, physical health, treatment planning, and follow-up. It is intended for comprehensive narrative documentation by psychiatrists, psychologists, and mental health nurses.
Psychiatrist
- Healthcare Team Meeting RecordA reusable structure for documenting healthcare team meetings. It records meeting logistics, participants, agenda items, discussion points, decisions, assigned actions, and details for the next meeting.
General Practitioner
- Nurse Practitioner Primary Care SOAP NoteThis template supports efficient SOAP documentation for Nurse Practitioners, covering the patient’s presentation, assessment, planned investigations and treatment, and patient education. It is suited to structured primary care documentation, including chronic condition management and confirmation of the patient’s understanding of the care plan.
Nurse Practitioner
- Emergency Department MDMA structured template for documenting emergency department medical decision-making. It covers the visit summary, relevant clinical findings, reassessment, shared decision-making, treatment, follow-up, education, medication changes, and lifestyle recommendations.
Emergency Medicine Specialist
- ADIME Nutrition Care DocumentationA structured template for dietitians to document nutrition assessment, diagnosis, intervention, and follow-up. It covers dietary intake, anthropometrics, activity, lifestyle factors, goals, and monitoring.
Dietitian
- Chronic Pain ConsultationThis template structures documentation for consultations about chronic pain in family medicine. It covers the presenting concern, subjective and objective findings, medical and social history, assessment, and a multidisciplinary plan including medications, activity, procedures, mindfulness, surgery, and patient education.
Family Medicine Specialist
- Family Medicine Hospital Discharge NoteA structured template for documenting a patient's hospital presentation, diagnostic evaluation, treatment course, physical examination, active diagnoses, and discharge follow-up plan. It supports clear communication of clinical findings, condition-specific management, and ongoing care needs.
Family Medicine Specialist
- RACGP Medical ReportA structured template for general practitioners preparing comprehensive medical reports for insurers. It covers administrative details, clinical findings, management, prognosis, functional impact, and certification.
General Practitioner
- Initial Speech-Language Evaluation NoteA structured template for documenting an initial speech-language pathology evaluation, including referral context, medical and developmental background, communication concerns, assessment findings, and recommendations. It supports consistent recording of intervention planning, referrals, home strategies, and clinician details.
General Practitioner
- Speech Pathology TherapyA structured template for recording speech pathology therapy sessions. It covers the presenting concerns, relevant history, objective findings, reports, interventions, outcomes, and follow-up planning.
Speech Pathologists
- NDIS Support Coordination Case NoteThis template is for documenting NDIS support coordination contacts and outcomes. It captures contact details, discussion points, actions, financial information, participant engagement, risks, recommendations, observations, and follow-up responsibilities.
Social Worker
- Supervision Summary NotesA structured template for occupational therapists to record the key topics, case discussions, feedback, actions, challenges, and professional development addressed during supervision. It supports comprehensive and organised documentation of supervision sessions.
Occupational Therapist
- Orthopaedic Consultation Update LetterA concise letter template for orthopaedic surgeons to update a patient’s GP on the presentation, examination findings, investigations, management, and follow-up. It also captures actions requested from the GP and patient, along with the relevant patient and clinician details.
Orthopaedic Surgeon
- Physiotherapy Vestibular Initial AssessmentA structured template for documenting an initial physiotherapy assessment of dizziness and vestibular symptoms. It covers symptom history, relevant medical and social factors, vestibular and balance testing, clinical reasoning, education, treatment, home exercises, and follow-up planning.
Physiotherapist
- Psychotherapy Progress Session NoteA structured template for documenting ongoing psychotherapy sessions, including presenting concerns, current functioning, mental state examination, session content, progress, risks, formulation, treatment planning, and follow-up actions.
Psychotherapist
- Mental Health Care PlanA structured template for documenting a comprehensive Mental Health Care Plan in primary care. It covers the presenting problem, psychiatric and psychosocial history, examination, formulation, treatment goals, management, referrals, safety planning and review.
General Practitioner
- Orthodontic Malocclusion AssessmentA reusable template for documenting an orthodontic assessment of malocclusion. It covers patient history, clinical and functional findings, diagnostic records, diagnosis, treatment planning, prognosis, and follow-up.
Dentist
- Comprehensive Initial Exercise Physiology AssessmentThis template supports comprehensive initial exercise physiology assessments, covering referral details, medical, musculoskeletal and social history, exercise history, barriers, goals, objective findings, treatment, assessment and ongoing planning. It is intended to structure documentation for conditions including musculoskeletal concerns, chronic pain and exercise-based interventions.
Exercise Physiologists
- Travel Medicine ConsultationA reusable template for documenting pre-travel medical consultations, including itinerary details, relevant medical and vaccination history, destination-specific disease risks, preventive advice, vaccination decisions, administration, and costs.
General Practitioner
- Issues, Goals, SOAP, and DAP LetterA reusable documentation structure for recording psychological and medical issues, client goals, SOAP notes, and a goal letter. It supports organized assessment, intervention planning, progress tracking, and communication of agreed goals to the client.
Clinical Physiologist
- NDIS Assistive Technology Funding RequestA structured form for documenting an NDIS participant’s details, proposed assistive technology, supplier and quotation information, and the supporting health professional’s recommendation and declarations.
Occupational Therapist
- Supervision NoteA structured template for documenting supervision sessions, including participants, session logistics, discussion topics, case reviews, feedback, follow-up tasks, reflections, and additional notes.
Psychologist
- Eating Disorder SymptomsA structured template for documenting symptoms associated with eating disorders, including eating behaviours, body image, emotional and social changes, and physical manifestations. It supports systematic clinical assessment while keeping entries grounded in the information provided.
Dietitian
- Urology Inpatient ConsultationA reusable template for documenting inpatient urology consultations, including the consultation reason, clinical and urologic history, examination, investigations, assessment, and management plan. It also captures follow-up, education, monitoring instructions, and additional urologic concerns.
Urologist
- Psychiatric Inpatient Discharge SummaryA structured template for documenting a psychiatric inpatient admission from presentation through discharge. It covers the admission context, psychiatric and medical history, investigations, hospital course, discharge treatment, mental status examinations, diagnoses, medications, and follow-up planning.
Psychiatrist
- New Prenatal ConsultA reusable template for documenting an initial prenatal consultation, including the current pregnancy, obstetrical and medical history, social circumstances, examination, investigations, ultrasound findings, vaccinations, impression, and care plan.
Obstetrician & Gynaecologist
- Medical Oncology ConsultationA structured template for documenting medical oncology consultations, including the presenting history, pathology, investigations, medical background, medications, examination, assessment, and treatment planning.
Medical Oncologist
- Postmenopausal BleedingThis template structures consultations for postmenopausal bleeding, covering the presenting concern, relevant histories, examination, investigations, assessment of endometrial cancer risk, and management. It supports consistent documentation of evaluation and follow-up planning.
Obstetrician & Gynaecologist
- SOAPA concise structure for documenting family medicine encounters using Subjective, Objective, Assessment, and Plan sections. It captures reported concerns, clinical findings, diagnostic impressions, and the documented management plan.
Family Medicine Specialist
- Dental examination and consultationA reusable dental documentation template for recording the presenting complaint, relevant medical, social, and dental history, oral hygiene, examination findings, risk assessments, investigations, diagnosis, treatment discussions, and follow-up advice.
Prosthodontist
- Doctor's Note for WorkA reusable medical letter template for documenting a patient's work restriction, including identifying details, examination findings, diagnosis, treatment plan, leave period, return-to-work guidance, and clinician information.
Hospitalist
- After Visit LetterA patient-facing letter summarising a clinic visit, including the reason for attendance, findings, diagnosis, treatment plan, medications, allergies, follow-up, and additional instructions.
Naturopath
- Home Health DocumentationThis template structures narrative home health visit documentation. It covers patient and visit context, assessment findings, vital signs, medications, care planning, interventions, education, progress, safety, coordination, follow-up, and clinician credentials.
Nurse
- Neuropsychology Intake Interview TemplateA structured framework for neuropsychological intake and clinical interview documentation. It covers referral details, presenting concerns, histories, functioning, mood, mental state, and behavioural observations while distinguishing information to omit from fields that remain as UNFILLED SLOTS.
Clinical Psychologist
- Initial Detailed ConsultA comprehensive initial consultation template for chiropractic assessment of a new patient. It covers the presenting concern, history, medication use, structured examination findings, working diagnosis, treatment, home care, and ongoing treatment planning.
Chiropractor
- Osteopath Initial ConsultA structured template for recording an osteopath’s first consultation with a patient experiencing a musculoskeletal concern. It covers the presenting complaint, history, medical background, goals, examination, diagnostic considerations, treatment delivered, and follow-up planning.
Osteopath
- Well Child VisitThis template supports documentation of routine pediatric well-child visits, including concerns, medical history, growth, development, nutrition, immunizations, examination findings, screenings, assessment, and preventive guidance. It helps organize a comprehensive evaluation and follow-up plan for the child's ongoing health.
Paediatrician
- IC Doctor LetterA reusable dietitian letter structure for documenting a referral assessment, including the relevant condition, medical and social history, bowel habits, dietary intake, anthropometry, clinical impression, recommendations, and follow-up. It is designed to support clear communication of personalised dietary advice without adding information that was not explicitly provided.
Dietitian
- ED AdmissionA structured emergency department admission template for documenting the presenting complaint, history, examination, investigations, assessment, emergency treatment, and ongoing plan. It supports concise, consistent capture of clinically relevant information and disposition details.
Emergency Medicine Specialist
- Psychiatry Progress NoteA concise structure for documenting psychiatric follow-up visits, including interim history, mental status, physical findings, investigations, clinical impression, and plan. It supports consistent recording of explicitly documented patient information without adding unstated details.
Psychiatrist
- Note Structurée de Consultation en Médecine GénéraleModèle structuré pour documenter une consultation de médecine générale, depuis l’interrogatoire et le contexte du patient jusqu’à l’examen clinique et la conclusion. Il organise les motifs, antécédents pertinents, données cliniques, diagnostics explicitement formulés, prises en charge et éléments de suivi.
Family Medicine Specialist
- Ericksonian Coaching SessionA structured template for coaching sessions that documents rapport building, session objectives, their importance, brainstorming, action planning, and the next session. It is intended to support personal development and stress-management work.
Psychologist
- Cardiology Clinic LetterA reusable template for patient-friendly cardiology clinic letters written directly to the patient. It covers diagnoses, primary care actions, management plans, clinical impression, medications, presentation, background, examination and investigations, treatment discussions, and management suggestions.
Cardiologist
- AppraisalA structured template for General Practitioners to document appraisal discussions, professional development, and revalidation progress. It covers the scope of work, supporting information, performance domains, SMART PDP objectives, preparedness, and longer-term development planning.
General Practitioner
- Pulmonology Respiratory Follow-Up NoteA structured follow-up template for documenting respiratory conditions, interval symptoms, investigations, examination findings, treatment response, and ongoing management. It also captures relevant medical, medication, social, assessment, and care-plan information.
Pulmonologist
- Care Plan ReviewA structured template for reviewing and updating a patient’s care plan. It covers medical history, medications, immunisation, allergies, psychosocial and functional information, significant events, and ongoing recommendations.
General Practitioner
- Family Medicine Specialist NoteA comprehensive family medicine visit template for documenting subjective and objective findings, review of systems, investigations, and a structured assessment and plan. It supports detailed documentation of multiple clinical issues while preserving explicit risk language and relevant follow-up details.
Family Medicine Specialist
- Psychiatric Discharge NoteA structured template for documenting discharge after psychiatric or substance use treatment. It covers the reason for discharge, admission details, treatment progress, suicide risk, risk mitigation, discharge status, prognosis, and follow-up planning.
Psychiatrist