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 8 of 13
- Detailed Review of SystemsA structured bullet-point template for documenting symptoms across all major body systems. It captures symptom characteristics such as onset, duration, severity, frequency, triggers, and associated or modifying factors when explicitly provided.
General Practitioner
- NHS GP ConsultationA structured English template for documenting general-practice consultations. It organises the consultation history, examination, impression, investigations, treatment, referrals, follow-up, and safety-netting while retaining explicit-information and formatting rules.
General Practitioner
- Follow-Up Letter to GPA concise letter template for updating a referring GP after a patient's psychiatric or mental health review. It captures the encounter's key findings and the agreed treatment plan to support continuity of care.
Psychiatrist
- Urology Kidney Stone Review NoteA structured template for documenting urology follow-up visits for patients with kidney stones. It covers current imaging, stone-related symptoms, previous stone history, medical history, assessment and plan, and prevention guidance.
Urologist
- Emergency Department Assessment NoteA structured template for documenting emergency medicine assessments, from the presenting complaint and relevant history through examination, investigations, diagnostic impression, and management. It supports concise but comprehensive recording of information explicitly provided about an emergency department encounter.
Emergency Medicine Specialist
- Comprehensive Sports Medicine NarrativeA structured template for documenting sports medicine and physiotherapy encounters involving injuries and musculoskeletal complaints. It covers the presenting complaint, illness history, medical background, subjective report, examination, clinical impression, and documented treatment plan without adding information that is not provided.
Sports Medicine Specialist
- Preoperative AssessmentA structured template for Physician Assistants to record a complete pre-surgical assessment. It covers patient details, medical and social history, observations, NEWS2 scoring, examination, investigations, anaesthetic discussions, consent, and perioperative planning.
Physician Assistant
- Initial Clinical InterviewThis template structures a first clinical interview for documenting presenting concerns, current functioning, psychiatric and medical history, developmental and social background, substance use, risk, mental state, assessment results, diagnosis, and formulation.
Psychologist
- Standard consultationA reusable general practice consultation structure for documenting up to four presenting symptoms, their characteristics, associated features, current treatments and management plans. It also covers relevant medical, social and family history, examination findings, and consent for AI-assisted note-taking.
General Practitioner
- Safety PlanA reusable clinical template for documenting an individualized safety plan during a mental health crisis. It covers warning signs, coping strategies, support people and places, professional contacts, environmental safety measures, and reasons for living.
Clinical Social Worker
- Mental Health AppointmentA reusable template for documenting a comprehensive mental health appointment, including the presenting concern, psychiatric history, medications, mental status examination, assessment, treatment, safety, support, and follow-up planning.
General Practitioner
- Mental Health Nursing SBAR Communication NoteA structured template for mental health nurses to communicate essential patient information using Situation, Background, Assessment, and Recommendation. It supports concise clinical communication, continuity of care, and timely interventions.
Mental Health Nurse
- Case FormulationA structured template for organising a patient’s contributing and protective factors across biological, psychological, and social domains. It supports concise clinical understanding and treatment planning without adding information that was not explicitly provided.
Psychologist
- Depression AssessmentA reusable template for documenting a comprehensive assessment of depressive symptoms, including presenting concerns, psychiatric and social history, mental status examination, risk, diagnosis, treatment, education, and referrals.
Family Medicine Specialist
- ASD Under 5sA structured template for documenting neurodevelopmental assessments in children under five with suspected autism spectrum disorder. It covers referral context, parental concerns, developmental and medical history, observations, autism assessment criteria, and follow-up documentation.
Developmental Paediatrician
- Perimenopause And Menopause GP Assessment TemplateA structured template for documenting a comprehensive perimenopause or menopause assessment in general practice. It covers patient details, history, symptoms, examination, investigations, diagnosis, management including HRT and lifestyle measures, referrals, prevention, education, follow-up, and applicable MBS item numbers.
General Practitioner
- ADHD AssessmentA structured template for documenting an ADHD evaluation, including mental status, observations, developmental and family background, diagnostic symptom criteria, and functional impact across settings.
Psychologist
- Mental State Examination (MSE) - AustraliaA structured Australian mental state examination template for documenting explicitly reported or observed information across appearance, behaviour, speech, mood, affect, neurovegetative symptoms, perception, thought, judgement, insight, and cognition.
Counselors
- Dental Specialist Consultation ReportA reusable letter structure for reporting a dental specialist consultation to the referring clinician. It covers the consultation summary, diagnosis, management, treatment completed, follow-up, referrals, attachments, and ongoing communication.
Dentist
- Medication RefillA reusable clinical documentation structure for medication-refill encounters. It captures patient details, visit purpose, treatment concerns, review of systems, objective findings, discussion, assessment and plan, preventive care, follow-up, and diabetes quality measures.
Nurse Practitioner
- Discharge SummaryThis template provides a structured discharge summary covering the most responsible diagnosis, medical profile, hospital course, complications, discharge plan, outstanding issues, and discharge medications. It supports a clear handover from inpatient care to follow-up care.
Emergency Medicine Specialist
- Medication ListA reusable medication-management template for documenting each medication’s names, class, indication, dosing, duration, side effects, benefits, dependence, and treatment response. It is suitable for organized medication tracking, including psychiatric care.
Psychiatrist
- Initial Pediatric Breastfeeding ReportA reusable template for documenting an initial breastfeeding consultation, including the infant’s weight, milk transfer, parental concerns, lactation assessment, care plan, follow-up, and contact details for communication with other healthcare providers.
Lactation Consultant
- Gastroenterology Follow-Up Visit NoteThis template structures concise gastroenterology follow-up documentation, covering the reason for review, gastrointestinal diagnoses, medications, clinical details, investigations, and assessment and plan. It supports organized capture of findings, management decisions, education, monitoring instructions, and follow-up needs.
Gastroenterologist
- Comprehensive Functional Medicine Visit NoteA reusable template for comprehensive Functional Medicine visit documentation. It covers subjective history, medications, vital signs, examination findings, laboratory results, assessments, treatment decisions, lifestyle guidance, and follow-up care.
Functional Medicine Specialist
- Évaluation Psychologique InitialeModèle destiné aux premières consultations de psychologie clinique. Il organise les informations recueillies sur le motif de consultation, le fonctionnement actuel, les antécédents, les risques, l’examen de l’état mental, les résultats aux tests, le diagnostic et la formulation clinique.
Psychologist
- Paediatric Developmental AssessmentThis template structures a comprehensive developmental assessment for a child referred with developmental concerns. It covers the referral, reviewed reports, background and medical history, development, daily functioning, examination, clinical impression and management plan.
Paediatrician
- IFS Clinical NotesA structured template for documenting Internal Family Systems therapy sessions. It captures the client’s presenting focus, internal parts and Self-energy, therapeutic techniques, shifts and insights, clinical observations, and next steps when explicitly discussed.
Therapist
- ADIME Medical Nutrition Therapy NoteA structured template for documenting nutrition assessments, diagnoses, interventions, and follow-up in medical nutrition therapy. It captures anthropometrics, dietary intake, nutrition-focused physical findings, SMART goals, and monitoring plans.
Nutrition & diabetics Specialist
- ADHD DSM-5 Diagnostic Criteria Documentation TemplateA structured template for documenting explicitly reported DSM-5 ADHD symptoms, supporting quotations, duration requirements, additional diagnostic conditions, and clinician-stated diagnostic classification. It covers inattentive, hyperactive/impulsive, combined, and predominantly presenting types without inferring unreported findings.
Psychiatrist
- Internal Medicine New Patient AssessmentA reusable template for documenting a comprehensive internal medicine assessment of a new patient. It covers the referral reason, patient details, presenting illness, medical and social history, medications, family history, examination, investigations, discussion summary, and management plan.
Internal Medicine Specialist
- Occupational Therapy Progress NoteThis template supports documentation of occupational therapy sessions, including activities, subjective and objective findings, assessment, treatment planning, and outstanding actions. It is intended to track progress, communicate updates, and guide future interventions, including for patients with developmental coordination disorders or similar conditions.
Occupational Therapist
- Dental Consultation Summary and Care PlanA reusable dental consultation summary for explaining the examination, findings, treatments, recommendations, follow-up, and patient questions in clear language. It supports patient understanding and continuity of dental care.
Dentist
- Pediatric Preventive Visit NoteA reusable template for routine pediatric well-child examinations by Nurse Practitioners. It organizes parental concerns, health and developmental history, physical assessment, diagnoses, preventive care, immunizations, counseling, and follow-up documentation.
Nurse Practitioner
- Community Nursing NoteA structured template for documenting community or home-visit nursing encounters. It covers patient-reported information, objective findings, nursing assessment, care planning, interventions, evaluation, and ongoing care needs.
Community Nurse
- Dermatology Consultation NoteA structured template for documenting dermatology consultations, including presenting concerns, examination findings, diagnoses, investigations, treatments, medical history, and follow-up plans. It supports concise, comprehensive recording of skin conditions and related management decisions.
Dermatologist
- Pediatric ENT Consultation NoteA reusable English template for documenting paediatric otolaryngology consultations, including the reason for referral, assessment, plan, subjective history, examination, endoscopy, and imaging. It supports comprehensive recording of ENT symptoms, findings, investigations, and follow-up arrangements.
Otolaryngologist
- Counseling Safety Evaluation and Follow-Up NoteA structured template for documenting presenting concerns, risk history, protective factors, current risk level, safety-planning steps, escalation or referral, and follow-up arrangements. It supports consistent recording of information relevant to safety and ongoing care.
Counselors
- ADHD Assessment and Management NoteA structured template for documenting ADHD assessments and follow-up reviews in children and adolescents in the South African context. It covers referral context, developmental and behavioural history, symptoms, functional effects, screening instruments, diagnostic reasoning, and management planning.
Child and Adolescent Psychiatrist
- Psychological Therapy Progress Letter to GPA concise letter structure for updating a general practitioner on a client’s progress through psychological therapy under the Medicare Better Access Initiative. It covers presenting concerns, therapy goals, ongoing issues, interventions, DASS-21 ranges, attendance, and a recommendation for further sessions.
Psychologist
- Medical ClerkingA structured template for documenting comprehensive medical admissions, from the presenting complaint and clinical history through examination, investigations, impression, and management. It supports consistent recording of relevant background, medications, allergies, social factors, observations, and follow-up plans.
Physician
- Comprehensive New Patient ConsultationThis template supports thorough initial consultations for plastic and reconstructive surgery. It captures the presenting concern, relevant history, examination, investigations, and explicit surgical or non-surgical assessment and planning details.
Plastic & Reconstructive Surgeon
- Endometriosis Follow-Up Consultation LetterThis template structures a follow-up endometriosis clinic letter, covering patient details, consultation history, examination findings, assessment, and management. It supports consistent documentation of ongoing symptoms, diagnostic considerations, treatment, follow-up, and counselling.
Gynaecologist
- Comprehensive Family Medicine New Patient SOAP NoteThis template supports comprehensive documentation of an initial family medicine consultation using the SOAP structure. It covers patient-reported information, laboratory results, review of systems, examination findings, diagnoses, and a detailed assessment and treatment plan.
Family Medicine Specialist
- Internal Medicine Consultation LetterA consultant-style internal medicine letter for communication with a referring physician. It organizes the referral context, medical history, medications, symptoms, examination, investigations, impression, and detailed management plan.
Internal Medicine Specialist
- Structured GP Consultation Note for EMISA concise NHS GP consultation structure for recording explicitly documented problems, history, examination findings, social context, clinical impression, and management plans in EMIS. It supports clear, efficient documentation without adding information that was not stated.
General Practitioner
- Addiction Medicine Initial AssessmentA reusable template for initial addiction medicine assessments, covering patient identification, presenting concerns, substance use, prior treatment, medical and psychiatric history, examination, risk, diagnosis, and management planning.
Addiction Medicine Specialist
- Emergency Department Acute Care EncounterA structured template for documenting emergency department encounters, including the presenting complaint, illness history, medical and social background, review of systems, examination, investigations, assessment, and plan. It supports rapid, comprehensive recording of acute-care evaluation and management.
Emergency Medicine Specialist