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 9 of 13

Initial Outpatient MSK Physiotherapy Assessment
This template structures the initial physiotherapy assessment for patients with musculoskeletal conditions in an outpatient setting. It covers the presenting condition, relevant history, goals, objective findings, treatment, assessment, and ongoing plan.
Physiotherapist
Initial Psychological Assessment Note
A structured template for documenting a client's initial psychological assessment, including presenting concerns, relevant history, current functioning, a 5P formulation, interventions, treatment goals, and follow-up planning.
Psychologist
Female infertility
A structured template for documenting the history and contributing factors relevant to female infertility. It covers reproductive and menstrual history, associated conditions, prior medical and surgical history, family history, and lifestyle factors.
General Practitioner
Mental Health Therapy Session Record
A structured template for documenting therapy sessions, including the client's presenting concerns, collaborative therapeutic work, interventions, goals, homework, safety matters, and follow-up plans. It supports consistent progress tracking while limiting documentation to information explicitly provided.
Accredited Mental Health Social Worker
SMART Treatment Plan
A structured behavioral health template for defining a client-centered SMART goal, specifying supporting interventions, and documenting how progress and outcomes will be evaluated.
Therapist
Comprehensive Initial Psychological Assessment
This template structures a psychologist’s comprehensive first-visit assessment. It covers presenting concerns, current functioning, personal and psychiatric history, risk, mental state, psychometric findings, formulation, and explicitly documented treatment planning.
Psychologist
Naturopathic Doctor Note
A comprehensive naturopathic documentation framework for recording a patient’s goals, symptoms, lifestyle, history, objective findings, assessment, and staged care plan. It supports holistic evaluation across nutrition, digestion, sleep, stress, energy, mood, mental health, and related clinical areas.
Naturopath
Comprehensive Biopsychosocial Intake
A structured initial-assessment template for documenting presenting concerns, symptoms, psychosocial history, relationships, cultural and spiritual factors, legal and educational background, employment, health, substance use, and prior treatment. It supports a holistic understanding of the client and informed treatment planning.
Psychotherapist
Adult ICU Morning Review Note
A structured template for adult intensive care consultants to record comprehensive morning ward-round assessments. It covers admission details, recent events, active issues, examination findings, investigations, treatment, prophylaxis, goals of care, impression, plan, and monitoring parameters.
Adult Intensive Care Specialist
IFS Treatment Plan
A structured template for planning Internal Family Systems therapy focused on identifying and assessing parts, developing unblending strategies, and strengthening access to Self. It supports exploration of parts’ functions, fears, interactions, and role in treatment planning.
Psychologist
Periodontal Disease
A reusable template for documenting comprehensive periodontal disease assessments. It covers patient and clinical history, extra-oral and intra-oral findings, investigations, diagnoses, prognosis, and treatment planning.
Dentist
Mental State Examination Notes
A structured template for documenting a comprehensive Mental State Examination. It covers patient information, appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight, judgment, and counselor details.
Counselors
Hospital Progress Note
A reusable English template for documenting inpatient progress, including patient identification, admission context, history, symptoms, examination, investigations, treatment planning, and discharge arrangements.
General Practitioner
Newborn Assessment
A structured template for documenting a newborn’s birth and nursery course, feeding and weight status, home safety, and early developmental behaviors. It supports a thorough assessment during the first days after birth and clear communication with caregivers.
Paediatrician
ER Note
This template structures emergency department documentation for family medicine specialists and other emergency care providers. It covers the patient's history, physical findings, vital signs, initial impression or diagnosis, and plans for further investigation, treatment, or follow-up.
Family Medicine Specialist
Adult ASD Diagnostic Interview – ADI-R + CAT-Q Integrated Script
A structured framework for adult autism assessments informed by the ADI-R and CAT-Q. It covers developmental history, social communication, restricted and repetitive behaviours, masking and compensation, education, health, mental health, risk, strengths, and clinician observations.
Allied Health Professional
NDIS Initial Assessment
A comprehensive occupational therapy template for documenting an initial NDIS assessment. It covers health history, supports, cognition, communication, behaviour, sensory and physical function, daily activities, home environment, goals and recommended services.
Occupational Therapist
Gynaecology Outpatient Clinical Note and GP Letter
A structured template for documenting gynaecology outpatient consultations, including symptoms, examination, investigations, assessment, discussion, management, and follow-up. It also provides a concise GP correspondence section based solely on the documented consultation.
Gynaecologist
Detailed SBAR Notes
A structured template for communicating urgent clinical information using Situation, Background, Assessment, and Recommendation. It captures the immediate concern, relevant clinical context, current findings, and specific actions or follow-up required.
General Practitioner
Detailed SOAP Template for Lactation Consultants
A structured SOAP framework for comprehensive lactation consultations involving the mother and infant. It captures feeding intake, breastfeeding observation, pumping, maternal and infant findings, oral and suck function, assessment, education, interventions, and follow-up planning.
Lactation Consultant
Skin Check
A structured template for documenting a comprehensive dermatology skin check, including relevant history, examination findings, lesion details, and follow-up guidance. It captures skin cancer risk factors, sun exposure, medication and allergy information, and a clear preventive care plan.
Dermatologist
Phone Consultation Progress Note
A reusable template for documenting orthopaedic updates discussed by telephone. It covers relevant history, current treatment and response, specialty progress, and follow-up planning.
Orthopaedic Surgeon
Workers' Compensation Psychological Report
A structured template for documenting a psychological evaluation related to a work-related injury, including patient, referral, employer, incident, work-status, pain, emotional-functioning, diagnostic, recommendation, and follow-up information.
Psychologist
Orthopaedic Consultation Summary for GP
A concise orthopaedic review-letter structure for communicating a patient’s diagnosis, management plan, clinical history, examination findings, imaging, and consultation discussion to the referring general practitioner.
Orthopaedic Surgeon
Initial Assessment
A structured template for Nurse Practitioners completing comprehensive initial psychiatric evaluations. It covers presenting concerns, DSM-V symptom domains, psychiatric and medical history, family and social context, substance use, risk, diagnosis, and treatment planning.
Nurse Practitioner
ADHD Diagnostic Assessment Letter for GP
A structured template for documenting an ADHD assessment for a general practitioner. It covers presenting concerns, psychiatric, medical, developmental, family, educational, occupational and psychosocial history, followed by detailed DIVA-5 symptom and functional-impact sections.
General Practitioner
Male Annual Wellness Visit Note
A structured template for documenting a male patient’s annual wellness visit, including preventive screening, medical history, medications, review of systems, examination findings, diagnostic results, and condition-specific assessment and plans. It supports comprehensive preventive and chronic-care documentation while preserving explicit procedure documentation when applicable.
Family Medicine Specialist
Holistic Health Intake Consultation Note
A comprehensive template for documenting holistic health consultations, including health goals, medical history, diet, lifestyle, stress, sleep, exercise, and other relevant habits. It also provides structured areas for recording recommendations and follow-up plans based only on the information provided.
Holistic Health Practitioner
Physical Therapist Initial
This template supports comprehensive documentation of a patient's initial physical therapy visit, covering the presenting history, symptoms, pain, functional limitations, relevant medical complexity, prior care, imaging, goals, objective findings, assessment, and plan. It is designed to organize clinically stated information and establish measurable rehabilitation goals.
Physiotherapist
Hearing Assessment
This template is used to document a comprehensive hearing evaluation, including patient details, referral reason, relevant history, examination results, assessment, and management. It supports structured recording of otoscopy, tympanometry, audiometry, diagnoses, and follow-up plans.
Audiometrist
New Clinic Patient Consultation
A concise template for documenting new neurology clinic consultations. It captures the diagnosis, management plan, relevant medical history, medications, consultation summary, examination, and the explanation provided to the patient.
Neurologist
Crisis
This template structures documentation of acute mental health and substance-use crises for addiction counselling. It covers subjective history, objective findings, assessment, treatment planning, follow-up, and patient education.
Addiction Counsellor
Disability Support Pension Support Letter
A reusable structure for preparing a General Practitioner’s support letter for a Disability Support Pension application. It covers patient and treating professional details, relevant conditions and treatment, functional limitations, work capacity, prognosis, and the declaration.
General Practitioner
Treatment Plan
A structured template for documenting a patient’s mental health treatment plan, including the diagnosis, goals, medications, therapies, lifestyle guidance, follow-up, education, and referrals. It supports consistent recording of comprehensive care and ongoing treatment planning.
Psychotherapist
GP Consultation
A structured template for documenting general practice consultations, whether conducted in person or by telephone. It covers the presenting history, ICE and risk factors, examination and investigations, clinical impression, diagnoses, management, follow-up, referrals and safety-netting advice.
General Practitioner
Orthopaedic New Patient Consultation
A structured template for documenting a new orthopaedic consultation. It covers the presenting concern, relevant history, examination, investigations, assessment and plan, follow-up, and CPT coding.
Orthopaedic Surgeon
SOAP Note for Naturopathy
A reusable SOAP framework for naturopathic consultations, covering reported concerns, history, examination findings, clinical assessment, and individualized care planning. It supports documentation of symptoms, lifestyle context, integrative interventions, testing, and follow-up.
Naturopath
Urology Follow-Up Visit Note
A structured template for concise urology follow-up documentation. It covers the chief complaint, prior urologic history, current symptoms and testing, examination, laboratory and imaging findings, assessment and plan, orders, follow-up, and conditional telehealth documentation.
Urologist
Hospitalist Inpatient Admission
This template supports comprehensive inpatient admission documentation by covering the presenting concern, history, review of systems, examination, investigations, assessment and plan, hospital-stay expectations, and encounter time.
Hospitalist
Process Notes
A psychotherapy session documentation template covering presenting concerns, progress and setbacks, current functioning, presentation, risk assessment, interventions, treatment planning, and supervision points. It supports structured tracking of therapy goals and clinically relevant session details without adding information that was not explicitly provided.
Psychotherapist
ADHD Review Appointment
A structured template for documenting paediatric ADHD follow-up visits. It captures current and discontinued medicines, school functioning, treatment effects, sleep, wellbeing, examination findings, investigations, clinical impression, and the management plan.
Paediatrician
Audiological report
A reusable template for documenting a comprehensive audiological assessment. It covers patient and referral details, case history, audiological test results, findings, impressions, recommendations, and clinician information.
Audiologist
Allergy and Immunology Follow-up
A reusable template for documenting allergy and immunology follow-up visits, including background history, interval changes, examination findings, skin prick testing, spirometry, and the assessment and follow-up plan.
Allergy and Immunologist
Urgent Care SOAP Note
A structured template for documenting urgent care appointments in SOAP format. It covers the patient’s reported history, objective findings, assessment, and explicitly stated management plan.
General Practitioner
Care Confirmation Letter
A formal letter template for confirming that a patient is receiving care and briefly describing the relevant condition or purpose. It includes patient identification, contact details, care confirmation, additional context, and clinician sign-off for sharing with an authorised third party.
General Practitioner
Progress Note
A structured template for physiotherapists to document a patient's current condition, objective findings, clinical assessment, treatment, education, and exercises. It supports concise, consistent records for tracking progress and guiding ongoing physical therapy.
Physiotherapist
Older Adult Care Planning Assessment
A structured template for documenting an older adult’s personal details, medical information, routines, support needs, safety considerations, care goals, and required services. It helps organise comprehensive information for coordinated elderly care planning and communication with caregivers.
Geriatric Medicine Specialist
Initial Pelvic Floor Physiotherapy Assessment
A structured template for documenting an initial pelvic health physiotherapy assessment. It covers patient context, subjective pelvic health symptoms, relevant history, goals, objective findings, issue-based assessment and treatment, and ongoing planning.
Physiotherapist