Clinical Note Template
This simple yet effective clinical note template will help you improve the accuracy and organization of your documentation process while saving you time.
Fact Checked by RJ Gumban.
What is a Clinical Note Template?
are a form of documentation that healthcare practitioners write while treating patients. These notes essentially document the medical history and treatment intervention of patients to ensure they are receiving the best quality healthcare possible. While the specific kind of information that you include in your clinical notes will depend on the type of healthcare you specialize in, the general format of clinical notes will remain the same. As such, utilizing a clinical notes template will greatly benefit you, as it will guarantee organization, consistency, and accuracy, all while saving you time. Clinical notes record information detailing an encounter that a practitioner has with their patient and the content of this encounter. Typically, this will include a primary complaint, history of presenting complaint, diagnosis, medication, allergies, physical examination, treatment plan, referrals, and general advice given to patients. In order to help you structure this information in an effective and consistent way, we have designed an intuitive clinical note template that can be downloaded and utilized within your practice.
Free Clinical Note Template
Check out these templates for clinical notes to improve your medical documentation, workflow, and treatment outcomes.
How to Use This Template For Clinical Note
As healthcare practitioners are required to complete an extensive range of different clinical and administrative tasks, finding solutions to save time without reducing the quality of work can be quite difficult. With our template, we have aimed to provide a resource to healthcare practitioners that simplifies clinical documentation while also improving the quality of the produced notes. In order to benefit from our clinical note template, you simply have to follow these four steps:
Step One: Access the PDF
Before you can make any changes to the clinical note template, you need to access the PDF. We’ve included a link to the document further down on this page and you simply have to click on it and you’ll be taken straight to the PDF. From here, you can save the document to your own device so that it is easily accessible whenever you need to write a note.
Step Two: Make the necessary edits
Following an interaction or encounter with a patient, it’s time to write a clinical note. You should access the template that you’ve previously saved on your device and begin adding the relevant information. In order to ensure your clinical notes are as accurate as possible, we recommend writing them immediately after a session with a patient. This will decrease the likelihood of forgetting any vital pieces of information, so you can focus on creating comprehensive documentation.
Step Three: Double-check for mistakes
Before you save your clinical note, you need to double-check it for mistakes. Ensure that you’re writing the note within the correct patient’s records and that all of the information you have included is accurate. If you notice a mistake and you have already signed the document, then you need to follow the correct protocol: cross the error out with a single line and then write the date and your initials. This guarantees transparency and makes it easier to interpret the information in clinical notes.
Step Four: Save the note securely
Clinical notes contain PHI and as such, they fall under HIPAA guidelines. When you have finished writing your clinical notes, you must store them securely. Both electronic and physical storage options are fine, as long as the appropriate safeguards are in place.
Clinical Note Example (Sample)
To help you visualize what our clinical note template will look like when completed, we’ve created a sample document. This will evidently differ from your own notes, but it should hopefully give you an insight into what how the clinical note template works and what type of information needs to be included.
Download this Clinical Note example here:
Who Can Use this Printable Clinical Note Template?
All kinds of healthcare practitioners are required to write clinical notes, and we’ve tried to keep this in mind as we’ve developed our template. As such, the template that we’ve designed is applicable to a broad range of different healthcare fields, including the following:
- Psychologists
- Psychiatrists
- General Practitioners
- Nurses
- Counselors
- Physical Therapists
- Psychotherapists
- Mental Health Therapists
- Occupational Therapists
- Speech Language Therapists
- Massage Therapists
Sometimes, healthcare practitioners will also specialize in different kinds of patients. Some of these variations include:
- Infants
- Children
- Teenagers
- Adults
- Families
- Couples
- Women
- Men
Regardless of which of these patients you work with (and chances are you will work with a combination of them), you will be able to use our clinical note template to record the details of your patient encounters. Our template is also applicable for practitioners who work by themselves or for those who work in a group practice.
Why is This Template Useful For Healthcare Practitioners?
Our clinical note template has a range of different uses for the day-to-day lives of healthcare practitioners, including the following:
- Structure: The clinical note template has a predesigned structure that helps to organize your documentation. This way, you can ensure all of the notes you write are consistent and adhere to the same format. Additionally, you can use the clinical note format to loosely structure the session with your patient. The template indicates the different areas that need to be covered during a patient encounter, and so you can use it to determine whether you are meeting all requirements.
- Comprehensive and accessible: The clinical note template ensures that your documentation is comprehensive and covers all necessary information. However, it has also been designed to be accessible and readable by other parties. The resulting note should sit somewhere perfectly between too complex and too simple.
- Saves time: One of the best outcomes of using a clinical note template is the time that it will save you. You no longer have to worry about organizing the structure and format of your clinical notes and you can instead spend this time focusing on the accuracy of your records.
Why Use Carepatron For Clinical Notes?
When it comes to writing clinical documentation, using a practice management system like Carepatron is one of the best ways you can improve your note-taking process while saving countless hours. In addition to being integrated with extensive note templates, Carepatron has a sophisticated voice-to-text transcription software. This allows you to speak into your device and the system will translate the words for you, generating clinical notes in record time. Carepatron is also entirely HIPAA-compliant and has robust storage capabilities. You can write all of your clinical notes on the platform before saving them using the system’s cloud-based technology. Carepatron employs electronic and physical safeguards, ensuring that your ePHI is safe and protected at all times. Making the decision to implement a new practice management software into your healthcare business may be daunting, but it’s undoubtedly one of the best decisions you can make. With Carepatron, you are guaranteed to streamline administrative and clinical processes, saving your practice both money and time.
Commonly asked questions
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:
- Patient basic information
- Primary complaint
- Diagnosis
- History of presenting complaint/illness
- Allergies and medications
- Physical examination
- Laboratory tests
- Assessments
- Treatment plan
- Referrals
- General advice given to patients
Clinical notes have a range of different 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. Clinical notes are also used by the healthcare practitioner to ensure their clinical decisions are well-informed.
Again, this depends on the specific encounter that your clinical note is recording. However, it’s a good idea to write clinical notes that are around 1-2 pages in length. This generally allows for the inclusion of all relevant information without becoming excessively lengthy.
