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 visit.
- Structure the note so the clinician’s findings, assessment, and any recommended next steps are explained clearly.
- Quickly generate a note ready for review and editing.
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 visits.
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 shift also resulted in clinicians spending more time writing clinical notes than ever. A joint report from the Canadian Medical Association (CMA) and the Canadian Federation of Independent Business (CFIB found that Canadian physicians collectively spend over 20 million hours each year on administrative tasks unrelated to patient care.
Clinical note templates have emerged as a way for clinicians, patients, and health services to retain the advantages of digital health records without the 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 minimises the mental fatigue involved in documentation, as one can simply follow the template rather than think about how to structure the note.
- Better patient care: A well-designed template helps the practitioner stay present during the appointment, so more of their attention goes to the patient rather than the page.
To build on these benefits, clinicians are increasingly turning to AI-enabled clinical note templates, like those available within Heidi’s platform. For example, Dr. Sanjay Mehta, a paediatric emergency physician and community paediatrician at Kindercare Paediatrics in Toronto, Ontario, has cut his daily charting time by roughly 50–60% since adopting Heidi. What once stretched into late evenings now wraps up in far less time, and his chair in the exam room has literally shifted: turned away from the screen, facing the family.
"My smile is now more genuine because I'm present and less stressed about typing," he says. That restored presence extends beyond the clinic. With documentation no longer following him home, Dr. Mehta describes feeling more energy at the end of the day, and a quiet but meaningful reduction in the mental weight that had built up over years of practice.
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, DAP, BIRP, GIRP, and PIRP are proven formats for effectively documenting a wide range of clinical encounters. As you build more experience and practice in more specialised 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 medical resident 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. In James's case, a SOAP notes template and a GP letter (Ortho) should be enough to handle his documentation.
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 specialised documentation needs.
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 and lessen the time you spend on 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. See if clinical notes or structured assessments work for you
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 gather 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 optimise from there.
Clinical Notes Template Example
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
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 will have you up and running with a specialty-appropriate, AI-enabled clinical notes template in seconds.
With Heidi by your side, your attention stays where it belongs: on your patient. Start a visit and the notes write themselves. When it's done, every document you need is ready, built in your templates, in your voice, from that single conversation.
Benefits of Heidi include:
- Less time spent on notes: Most Canadian clinicians using Heidi reduce their daily documentation time by around 66%.
- Improved patient care: With the notes handled, you will have more time, energy, and space to focus on patient care.
- Enhanced clinician well-being: Less time on documentation means you can finish on time and not spend your evening catching up on notes.
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.
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.
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 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.
FAQs About 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.