Clinical Notes Template with Example

Clinical Notes Template

A primary care physician created this problem-based clinical note template. It includes sections for documenting the history of present illness, review of systems, physical exam, and assessment and plan. Using this template enables any doctor or nurse to:

• Create a concise note that contains all relevant information from the encounter.
• Structure the note so the clinicians findings, assessment, and any recommended next steps are explained clearly. 
• Use AI to auto-generate a note for the clinician to review and apply any necessary edits.‍‍

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What is a Clinical Notes Template?

A clinical notes template is a structured document healthcare professionals use to improve clinical documentation quality, accuracy, and efficiency. The template prompts the clinician to record specific details in a predetermined order, reducing the time and cognitive load of documenting patient encounters.

In this article, we’ll provide examples of clinical notes templates and then guide you through choosing a template that’s tailored to your unique practice needs and style. We’ll also cover how AI-enabled templates can make clinical documentation faster and easier.      

Benefits of Using a Clinical Note Template

The migration from paper to electronic health records brought many benefits. However, it’s widely acknowledged that this digital transformation also resulted in clinicians spending more time writing clinical notes than ever. 

Clinical note templates have emerged as a way for clinicians, patients, and health services to retain the advantages of digital health records without subjecting healthcare practitioners to unnecessary administrative burden. A summary of the key benefits of clinical notes templates includes:

• Faster documentation - A good clinical notes template can significantly reduce the time spent on documentation.
• Higher note quality - Because the template covers all necessary aspects of documentation, the resulting note is often more complete and easier to follow.
• Reduced cognitive load - Many clinicians remark that a clinical notes template minimizes the mental fatigue involved in documentation, as one can simply follow the template rather than think about how to structure the note.
• Enhanced patient care - A well-designed template supports good clinical decision-making and enables the practitioner to be more present during the interview, both promoting better patient outcomes. 

To amplify the benefits described above, clinicians are increasingly turning to AI-powered clinical note templates, like those available within Heidi Health’s AI medical scribe. For example, Neil Aitken, owner of Kinetic Physio in Scotland, saves 1-2 hours per day on documentation by utilizing custom templates he created in Heidi.

Neil describes Heidi’s AI-supported documentation platform as a “game changer.” With the burden of documentation lifted, he reports feeling less mentally fatigued after a long day in clinic and has more time to spend at home with his kids. This improved focus and vitality also enables Neil to channel more time into his clinical work and business.

Specialty vs. General Clinical Notes Templates

If you’re newer to practice or conducting more routine sessions, a generic structure like a SOAP notes template might suit your needs. SOAP, along with DAP, BIRP, GIRP, and PIRP are proven formats for effectively documenting a wide range of clinical encounters. But, as you build more experience and practice in more specialized or complex areas, your template needs will likely evolve.

To illustrate this point, consider the documentation needs of two doctors: James and Sarah.

‍James is a junior doctor working in the fracture clinic of a busy hospital. Most of his appointments are fairly routine and involve assessing patients at follow-up appointments and then drafting a letter to their primary care doctor. James could probably complete all his documentation via a SOAP notes template and GP letter (Ortho).

Sarah, on the other hand, is a consultant geriatrician who works for a home visiting service delivering “hospital-in-the-home” type care. Sarah is the primary clinician for her patients and is responsible for everything from intake and assessment to developing and administering a treatment plan and writing letters to other involved specialists. Sarah would likely need several purpose-built clinical notes templates to cover all of her specialized documentation needs.

Where to find a clinical notes template

You can build your own clinical notes template, but it’s far more efficient to find one already tailored to your practice setting and then adapt it to your needs (if required).

Heidi’s Template Community contains dozens of field-tested, specialty-appropriate clinical notes templates that you can browse for free at your leisure. Templates in the community can be filtered by popularity, location, specialty, and category. Simply sign up for a free account (no credit card required) and you can try Heidi’s templates today. 

How to Choose a Clinical Notes Template

Sometimes, even with access to a range of specialty-appropriate clinical notes templates, finding the right one can feel a little overwhelming. Here are four tips to help you choose a template to start benefiting from more streamlined clinical documentation.

1. Decide how many templates you need

Most practitioners maintain a small library of clinical note templates. A preliminary list of the templates you might need is an initial assessment, progress note, referral letter, discharge summary, and treatment report.

2. Have a reference note for comparison

Before you start your search, get an example of a high-quality note written by yourself or another clinician. You might like to highlight certain sections or list the elements that make this particular note stand out. Then, when evaluating a clinical notes template, view it side-by-side with your reference note, asking yourself, “Is this template likely to produce something as good as my reference note?”

3. Progress notes vs. structured assessments

Basic formats like SOAP, DAP, or BIRP often work well for routine follow-ups. However, initial assessments, specialist consultations, and complex cases usually require more comprehensive, purpose-built templates to capture all necessary clinical information.

4. Remember you can edit the template

Don't become paralyzed by trying to find the “perfect” template. The truth is, you’ll probably need to tweak whichever templates you choose at least a little. If you’re struggling to find a clinical notes template that’s “just right,” choose one close to what you need and optimize from there.

Clinical Notes Template Example

Having a clinical notes template that you fill in manually, whether by hand or on a computer, may save you time on notes. However, many providers still find that the burden of keeping up with clinical documentation takes away from patient care and maintaining a healthy work-life balance.

Make clinical note-taking easier with AI-enabled templates

No matter your background or practice area, Heidi’s AI medical scribe will have you up and running with a specialty-appropriate, AI-enabled clinical notes template in seconds.

When you see a patient with Heidi, all you need to do is press “Transcribe” and the AI processes the conversation and is ready to produce your notes. After the visit, just choose the clinical note and documents you need, and Heidi will automatically generate them according to your templates.

Benefits of Heidi include:

• Less time spent on notes - Most clinicians utilizing Heidi reduce their daily documentation time by around 50%.
• Improved patient care - With Heidi looking after your notes, you will have more time, energy, and space to focus on patient care.
• Enhanced clinician well-being - Less time on documentation enables clinicians to achieve better work-life balance.

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Free Clinical Notes Templates

Dental Clinic Notes Template

This Child Check-up (Dental) template is designed for dentists conducting routine dental examinations for children. The structured dental clinical note template guides the dentist through the entire examination process, from oral hygiene assessment to risk assessment, treatment discussions, consent, and orthodontic assessments.

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Clinical Supervision Notes Template

This clinical supervision notes template is a comprehensive tool designed for healthcare managers to oversee and support their staff. It helps outline roles, responsibilities, and performance goals, ensuring clarity and alignment between supervisors and employees. Sections for setting SMART goals, identifying training needs, and establishing a support structure are included.

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Mental Health Clinical Notes Template

This Mental Health Appointment template is designed for clinicians to document comprehensive mental health evaluations. A complete mental health clinical notes template, it includes sections for the reason for visit, presenting issues, past psychiatric history, current medications, mental status examination, assessment, treatment plan, safety assessment, patient and family support, and next steps.

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FAQs About Clinical Notes Template

What should be recorded in a clinical notes template?

The note produced with a clinical notes template should capture all essential information from a patient encounter. The exact content varies based on your specialty and practice requirements. However, most notes at minimum include the date, patient demographics, reason for visit, assessment, details of any treatment provided, and follow-up plans.

How do I summarize clinical notes?

Heidi’s AI medical scribe will automatically summarize clinical notes for you either by using a summary template or the Ask Heidi feature. Many clinicians use this to provide a summary of the session to patients or other involved healthcare professionals. The summary can either be printed out or emailed.

Can I create my own clinical note template?

Yes! Heidi provides several options for creating your own clinical notes template via our template editor. Users can: a) Supply a reference note and ask Heidi to create a template from it; b) Choose an existing template from the community and tweak it; c) Create your own template from scratch. Everything you need to know is covered in our Help Centre article, Creating Templates in Heidi.