Clinical Note Template

The specific information included in a clinical note depends on the type of healthcare you work in and the session that you had with a client. However, there are certain kinds of information that should be included in clinical notes such as the patient's basic information, primary complaint, history, allergies, and medication, examinations conducted, additional notes about clinical management, and the signature of the healthcare provider for accountability.

Clinical notes have various uses. They are often shared between members of a patient's care team to improve communication and coordination of care. They can also be used in insurance and legal situations. Healthcare practitioners use clinical notes to ensure their clinical decisions are well-informed.

Again, this depends on the specific encounter that your clinical note records. However, it's a good idea to write clinical notes that are 1-2 pages in length. This generally allows for the inclusion of all relevant information without becoming excessively lengthy.