Clinical Notes Template
Free clinical notes templates for healthcare providers. Learn proper documentation formats, download professional templates, and discover how to write clinical notes efficiently.
What Are Clinical Notes?
Clinical notes are written documentation of patient encounters in healthcare settings. They record the reason for the visit, clinical findings, medical decision-making, and treatment plans. Clinical notes serve as the primary communication tool between healthcare providers and form the legal medical record.
High-quality clinical documentation is essential for:
- Continuity of Care: Enabling seamless handoffs between providers and care settings
- Legal Protection: Creating a defensible record of care provided
- Billing & Reimbursement: Supporting claims with documented medical necessity
- Quality Improvement: Facilitating outcome tracking and care analysis
- Patient Safety: Ensuring critical information is accessible when needed
Types of Clinical Notes
Different clinical scenarios require different documentation formats. Choose the note type that best fits your practice and patient encounters.
SOAP Notes
Subjective, Objective, Assessment, Plan format for structured documentation
Progress Notes
Ongoing documentation of patient treatment and response
H&P Notes
Comprehensive history and physical examination documentation
Procedure Notes
Documentation of medical procedures and interventions
Consultation Notes
Specialist evaluation and recommendations
DAP Notes
Data, Assessment, Plan format for mental health
Essential Components of Clinical Notes
Complete clinical documentation includes these core components to ensure thorough, compliant records.
Patient Identification
- Full name
- Date of birth
- Medical record number
- Date of service
- Provider name
Legal requirement for all clinical documentation
Chief Complaint (CC)
- Patient's primary concern
- Duration of symptoms
- Patient's own words when possible
Establishes the reason for the visit
History of Present Illness (HPI)
- Onset and duration
- Location and quality
- Severity and timing
- Aggravating/relieving factors
- Associated symptoms
Provides context for diagnosis
Review of Systems (ROS)
- Constitutional symptoms
- Relevant body systems
- Pertinent positives/negatives
Supports medical decision-making
Physical Examination
- Vital signs
- General appearance
- System-specific findings
- Pertinent normal findings
Objective clinical findings
Assessment & Plan
- Working diagnosis
- Differential diagnoses
- Treatment plan
- Medications
- Follow-up
- Patient education
Clinical reasoning and next steps
Clinical Note Template
A comprehensive clinical note template suitable for most outpatient encounters. Customize as needed for your specialty.
General Clinical Note Template
CLINICAL NOTE Patient: [Name] DOB: [Date] MRN: [Number] Date: [Today's Date] Provider: [Name], MD Visit Type: [New/Follow-up] CHIEF COMPLAINT: [Patient's primary concern in their own words] HISTORY OF PRESENT ILLNESS: [Detailed narrative of the presenting problem including onset, duration, location, quality, severity, timing, context, modifying factors, and associated symptoms] PAST MEDICAL HISTORY: ā¢ [Condition 1] ā¢ [Condition 2] MEDICATIONS: ā¢ [Medication 1] - [dose, frequency] ā¢ [Medication 2] - [dose, frequency] ALLERGIES: ā¢ [Allergy 1] - [reaction type] REVIEW OF SYSTEMS: Constitutional: [positive/negative findings] [Relevant systems based on chief complaint] PHYSICAL EXAMINATION: Vitals: BP [___] HR [___] RR [___] Temp [___] SpO2 [___] General: [appearance, distress level] [System-specific examination findings] ASSESSMENT: 1. [Primary diagnosis] - [ICD-10 code if applicable] 2. [Secondary diagnosis] PLAN: 1. [Diagnostic tests ordered] 2. [Medications prescribed] 3. [Referrals] 4. [Patient education provided] 5. [Follow-up: timeframe and conditions for return] ______________________________ [Provider Signature] [Date/Time]
Clinical Documentation Best Practices
Follow these principles to create clinical notes that are legally defensible, clinically useful, and efficient to produce.
Be Timely
Document within 24 hours of the encounter while details are fresh
Be Accurate
Record facts objectively without assumptions or judgments
Be Complete
Include all relevant information for continuity of care
Be Concise
Avoid unnecessary verbiage while maintaining completeness
Be Legible
Use clear language and proper formatting
Be Professional
Maintain objectivity and avoid inappropriate comments
Common Documentation Mistakes to Avoid
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CC: Follow-up for type 2 diabetes
HPI: 58 y/o male with T2DM presents for routine follow-up. Reports good compliance with metformin. Denies polyuria, polydipsia. Home glucose readings 110-140 mg/dL fasting...
Assessment: Type 2 diabetes mellitus, well-controlled (E11.65)
Plan: Continue metformin 1000mg BID. Order A1C and metabolic panel. RTC 3 months.
Frequently Asked Questions
What are clinical notes in healthcare?
Clinical notes are written documentation of patient encounters that record symptoms, examination findings, diagnoses, and treatment plans. They serve as legal records, support care continuity, and are required for insurance billing. Common formats include SOAP notes, progress notes, and H&P notes.
What should be included in a clinical note?
A clinical note should include: patient identification, date and time, chief complaint, history of present illness, relevant medical history, physical examination findings, assessment/diagnosis, treatment plan, medications prescribed, follow-up instructions, and provider signature. Additional elements may include vital signs, lab results, and patient education provided.
How can I write clinical notes faster?
To write clinical notes faster: use templates and macros, dictate notes using voice recognition, document during the visit, use AI scribes like PatientNotes (from $50/month) to auto-generate notes from conversations, keep documentation concise yet complete, and develop consistent abbreviations. AI documentation tools can reduce note-writing time by 70%.
What is the difference between clinical notes and progress notes?
Clinical notes is a broad term encompassing all patient documentation, while progress notes specifically document ongoing care and treatment updates. Progress notes are a type of clinical note typically written for follow-up visits, showing how a patient is progressing over time. Other clinical note types include initial evaluations, consultation notes, and procedure notes.
Are there legal requirements for clinical documentation?
Yes, clinical documentation must meet legal and regulatory requirements including: documentation within 24-48 hours of encounter, legible and complete records, proper patient identification, date and signature on all entries, correction protocols for errors (no deletions), HIPAA compliance for privacy, and specific requirements for Medicare/Medicaid billing.
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