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 7 of 13
- Psychology Meeting Minutes TemplateThis template is for recording and organizing meeting minutes for psychologists and mental health professionals. It covers meeting logistics, attendees, agenda items, discussion points, decisions, action items, and details for the next meeting.
Psychologist
- Ortho Concise NoteA structured template for orthopaedic consultation documentation. It covers the patient's symptoms and relevant history, examination findings, differential diagnoses, planned investigations, and follow-up arrangements.
Orthopaedic Surgeon
- Medical Certificate for Return to WorkA reusable English template for documenting medical clearance to resume employment after treatment. It covers the assessment, any temporary workplace limitations, follow-up arrangements, and provider verification.
General Practitioner
- Gyne/PAP VisitA structured template for routine family medicine gynaecological and cervical screening visits. It captures menstrual and cervical screening history, consent, examination findings, infection swabs, bimanual examination, assessment, and follow-up.
Family Medicine Specialist
- Female Annual Wellness Visit NoteA reusable template for documenting a female patient’s annual wellness visit. It covers preventive health history, screening discussions, medications and supplements, review of systems, physical examination, diagnostic results, assessment and plan, and any procedures performed.
Family Medicine Specialist
- Pediatric SLP Assessment ReportA reusable template for documenting a comprehensive pediatric speech-language assessment. It covers consent, background history, communication and play skills, speech and language domains, recommendations, therapy goals, and follow-up.
Speech Pathologist
- Couples Intake QuestionnaireA structured intake questionnaire for couples therapy that explores relationship history, communication, conflict patterns, emotional connection, commitment, and areas of difficulty. It supports an initial assessment of the couple’s concerns and relational strengths.
Behaviour Therapist
- Enhanced Primary Care and Bariatric Review LettersA reusable template for physiotherapists and allied health clinicians to prepare an Enhanced Primary Care correspondence letter and a post-sleeve-gastrectomy review letter. It captures referral details, clinical history, weight and dietary assessment, activity, education, and follow-up planning.
Physiotherapist
- Initial Hand Surgery Consultation NoteA structured template for documenting initial hand-surgery consultations, including the presenting history, examination, diagnostic studies, diagnoses, and treatment plan. It also provides reusable examination macros for common hand and shoulder conditions.
Hand Surgeon
- Ärztliche Notiz – Allgemeine VorlageDiese Vorlage strukturiert die Dokumentation allgemeinmedizinischer Patientenkontakte von Anlass und Anamnese über Untersuchungsbefunde und Diagnosen bis zu Therapie, Maßnahmen und Empfehlungen. Sie eignet sich für akute Vorstellungen, Routine- und Vorsorgetermine sowie Verlaufskontrollen.
General Practitioner
- GP Consultation NoteA structured template for documenting general practice consultations in a concise, clinically complete format. It covers presenting symptoms, relevant history, examination findings, clinical impression and treatment planning while using only explicitly documented information.
General Practitioner
- Hypertension Review NoteA structured template for documenting primary care reviews of hypertension, including the consultation summary, history, symptoms, vital signs, laboratory findings, assessment, treatment, lifestyle guidance, and follow-up.
Family Medicine Specialist
- Mental Health Crisis Safety Planning WorksheetA structured safety-planning template for documenting warning signs, personal coping methods, sources of social distraction, crisis contacts, and professional or emergency supports.
Mental Health Counselor
- Ophthalmology Patient LetterA concise structure for ophthalmology correspondence documenting eye-specific visual acuity, intraocular pressure, diagnoses, clinical findings, assessment, management, and follow-up. It supports clear communication of encounter details to the patient.
Ophthalmologist
- Split Notes for Multiple PatientsA reusable structure for documenting consultations with several patients in one session. It organises each patient’s summary, history, examination, assessment and plan while keeping information attributed only when explicitly linked.
General Practitioner
- New Ophthalmology Patient Visit NoteA reusable template for comprehensive ophthalmology new-patient examinations. It organizes history, ocular examination findings, diagnostic testing, procedures, assessment and plan, follow-up, education, referrals, prescriptions, correspondence, scheduling details, and patient demographics.
Ophthalmologist
- Psychotherapy and Art Therapy Progress NoteA comprehensive structure for documenting psychotherapy and art therapy sessions, including presenting concerns, current functioning, risk, mental state examination, formulation, interventions, progress, and treatment planning.
Psychotherapist
- Gastroenterology ConsultA reusable template for documenting comprehensive gastroenterology consultations, including the consultation reason, clinical history, medical and social background, examination, investigations, and management plan. It supports organized assessment and follow-up for gastrointestinal symptoms and conditions.
Gastroenterologist
- Family planning and contraceptive adviceA reusable template for documenting contraception-focused consultations, including patient, medical, lifestyle, and reproductive history. It records options discussed, factors influencing the choice, the current plan, education, follow-up, and documentation details.
General Practitioner
- Dietitian Meeting Action RecordA reusable template for documenting meetings in clinical or healthcare settings. It captures meeting details, participants, agenda topics, discussion points, decisions, assigned actions, and plans for the next meeting.
Dietitian
- Letter to GPA structured correspondence template for colorectal surgeons to update a general practitioner about a patient's presentation, clinical findings, discussion, and management plan. It supports concise communication of relevant investigations, treatment arrangements, and follow-up considerations.
Colorectal Surgeon
- General Treatment NoteThis template is for podiatrists documenting routine foot-care visits, including the patient’s reported concerns, clinical findings, treatment delivered, and follow-up planning. It also captures relevant nail and skin care details, home-care advice, and non-clinical updates that support continuity of care.
Podiatrist
- Emergency Psychiatry ConsultationA structured template for documenting an emergency psychiatric consultation, including the presenting concern, clinical history, risk assessment, mental status examination, diagnostic impression, and care plan. It supports thorough, neutral documentation based only on the information provided.
Psychiatrist
- Biopsychosocial AssessmentA comprehensive clinical assessment template for documenting presenting concerns, treatment and risk history, psychosocial context, mental status findings, diagnosis, and recommendations. It also supports recording treatment categories and areas of functional concern.
Clinical Social Worker
- SLP Session NoteA reusable template for documenting speech-language pathology sessions, including the patient’s reported concerns, session observations, and recommendations. It supports tracking speech, language, cognitive-linguistic, and behavioral findings without pre-populating any clinical information.
Speech Pathologist
- Abnormal Menstrual Bleeding Consultation NoteA structured template for documenting consultations about abnormal uterine bleeding. It covers the presenting concern, relevant medical, gynecological, obstetrical, social and family histories, examination, investigations, assessment and management plan.
Obstetrician & Gynaecologist
- Client LetterA reusable letter structure for dietitians to summarize education, interventions, and progress monitoring discussed with a client. It supports clear follow-up communication while including only details explicitly stated in the information provided.
Dietitian
- Initial EvaluationThis template structures a comprehensive initial psychiatric evaluation for documenting presenting concerns, psychiatric and medical history, mental status, risk, diagnosis, treatment, and functioning. It supports a thorough and consistent record of symptoms, background, clinical impressions, and care planning in mental health settings.
Nurse Practitioner
- Routine Check-Up and CleaningA reusable template for documenting a routine dental examination and cleaning visit. It covers history updates, oral hygiene, extraoral and intraoral findings, periodontal and radiographic assessments, procedures, diagnoses, recommendations, referrals, education, and recall planning.
Dentist
- Dermatology ConsultationA reusable template for documenting dermatology consultations involving skin lesions, rashes, acne, and related concerns. It covers the consultation reason, history, examination, assessment, investigations, treatment, instructions, understanding, referrals, and follow-up.
General Practitioner
- Multi-Patient Emergency Shift HandoverA structured template for handing over multiple emergency department patients during shift changes. It captures each patient’s location, identifying details, presentation, relevant history, current treatment, investigations, and ongoing plan using only explicitly provided information.
Emergency Medicine Specialist
- Medical Oncology Follow-upA structured template for documenting medical oncology follow-up visits, including the patient's oncologic history, current treatment, clinical status, recent laboratory and imaging findings, and assessment and plan.
Medical Oncologist
- DIVA-5A structured template for documenting the DIVA-5 assessment of ADHD symptoms in adults and children. It covers inattentive and hyperactive-impulsive symptoms, developmental history, cross-setting presentation, functional impact, and alternative explanations.
Psychiatrist
- Hyperthyroidism Referral LetterA referral letter template for communicating an assessment of hyperthyroidism or subclinical hyperthyroidism to the referring doctor. It covers the patient's history, medications, allergies, examination findings, and assessment and management plan.
Endocrinologist
- GP Emergency Trauma Assessment NoteA structured template for documenting emergency trauma evaluations from pre-arrival information through primary and secondary surveys, assessment, interventions, and disposition. It captures vital signs, airway and injury findings, procedures, consultations, and changes in condition for comprehensive trauma care documentation.
General Practitioner
- Implant consultation templateThis template supports comprehensive documentation for maxillofacial dental implant consultations, including patient details, tooth condition, imaging, treatment planning, medical history, preferences and follow-up care.
Maxillofacial Surgeon
- Rheumatology OPD ClinicA structured template for documenting rheumatology outpatient consultations, including diagnoses, treatments, investigations, disease activity, discussion, actions for primary care, and the management plan. It supports detailed progress notes while ensuring that only information explicitly provided is recorded.
Rheumatologist
- EMDR Therapy Target Planning TemplateA structured template for organizing EMDR therapy targets, including the client's presenting issues, priority concern, related beliefs, past experiences, present triggers, and future fears or triggers.
Psychologist
- Initial Paediatric Medical LetterA structured template for initial paediatric correspondence to a referring clinician. It captures referral concerns, medications, services, growth measurements, clinical summaries, examination findings, family discussions, and management recommendations.
Paediatrician
- SOAP NoteA concise structure for documenting family medicine encounters in Subjective, Objective, Assessment, and Plan sections. It organizes reported concerns, findings, diagnoses, and care plans while including only information explicitly present in the provided material.
Family Medicine Specialist
- Operation Note (Ortho)This template is used by orthopaedic surgeons to document the procedure performed, wound closure, and post-operative instructions. It supports concise operative documentation for procedures such as arthroscopy, joint replacement, and fracture fixation.
Orthopaedic Surgeon
- Dysphagia Assessment NoteThis template is used by Speech and Language Therapists to document the assessment and management of swallowing difficulties. It covers referral details, relevant history, oro-motor, food and drink findings, recommendations, and the intervention plan.
Speech and Language Therapist
- Contraception CounsellingA reusable template for documenting contraception counselling encounters, including relevant medical, gynaecological, family and lifestyle history, patient preferences, contraceptive options discussed, advice, education materials and sign-off details.
General Practitioner
- Geriatric Medicine Comprehensive AssessmentA structured template for documenting a comprehensive geriatric assessment, including medical history, medications, symptoms, function, social and family context, examination, investigations, and care planning. It also supports recording cognitive screening, pharmacy details, follow-up, and relevant administrative information.
Geriatrician
- Detailed Home Health Nursing NotesA reusable template for documenting home health nursing visits, including patient and visit details, clinical and physical assessments, medical management, interventions, education, feedback, and follow-up planning. It supports comprehensive, explicit documentation of care provided and ongoing needs.
Nurse
- Chronic Condition Exercise Physiology Initial AssessmentThis template supports comprehensive initial documentation by an Exercise Physiologist for a client with a chronic condition. It covers the client’s background, concerns, functional difficulties, goals, assessments, and prescribed exercise and lifestyle interventions, with particular attention to chronic pain and mobility.
Exercise Physiologists
- Comprehensive Conversation SummaryA detailed template for documenting a conversation with a colleague, including its factual content, emotional tone, relational dynamics, notable wording, outcomes, reflections, and possible next steps.
Social Worker
- Primary Care Mental Health Follow-Up NoteThis template is for documenting ongoing psychology follow-up visits, including the presenting history, psychiatric symptoms, mental status examination, and treatment plan. It supports tracking progress related to concerns such as depression and anxiety in general and primary care settings.
General Practitioner