Medical note templates and examples
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Acupuncture SOAP Note
Documents the patient's concerns, relevant medical and lifestyle history, examination findings including pulse and tongue observations, and a TCM assessment. It also records treatment principles, acupuncture and other modalities, lifestyle advice, referrals, and follow-up.
Acupuncturist · Note
Addiction Counseling Progress Note
Records the client's substance-use concern and timeline alongside psychiatric, medical, medication, allergy, family, and social history. It includes a mental status examination, risk assessment, clinical summary, counseling interventions, harm-reduction steps, and follow-up.
Addiction Counselor · Note
Addiction Medicine Consult
Captures a focused addiction medicine history, including substance use, prior treatment, withdrawal or overdose history, psychiatric and medical background, and social context. It also documents examination and completed investigations before a numbered assessment and plan covering treatment, harm reduction, referrals, and follow-up.
Addiction Medicine Specialist · Note
Admission Note
Organizes an admission history with a chronological, problem-focused HPI and review of systems, followed by medical, medication, allergy, family, and social history. It records examination and completed investigations, then summarizes the assessment and plan and relevant best-practice items.
All Specialties · Note
Adolescent Clinic Follow-Up Note
Documents an adolescent follow-up with subjective concerns and HEADSS details when available, followed by growth measures, vital signs, examination, and relevant lab or imaging results. It ends with an assessment and clear, line-by-line plan.
Pediatrician · Note
Allergy Consult
Captures a focused allergy consultation, including symptom chronology, triggers, relevant atopic and medical history, medications, allergies, family and environmental context. It records examination and completed testing before an assessment and plan for testing, avoidance, treatment, education, and follow-up.
Allergy And Immunologist · Note
Allergy Follow-Up Note
Tracks allergic symptoms, triggers, associated features, treatment response, and daily impact at follow-up. It records vital signs, examination, available allergy testing, clinical impression, and next steps such as medication changes, avoidance, education, and return precautions.
Allergy And Immunologist · Note
Allied Health Initial Assessment
Documents the referral concern, symptom course, medical background, medications, allergies, and social context alongside mobility, transfers, daily activities, communication, cognition, and pain. It summarizes observed function and examination findings, then sets therapy goals, interventions, education, referrals, and follow-up.
Allied Health Professional · Note
Alternative Medicine Initial Evaluation
Documents an initial complementary and alternative medicine evaluation, including symptom history, medical and lifestyle background, examination, investigations, assessment, and therapies or follow-up recommendations.
Alternative Medicine Practitioner · Note
Anesthesia Pre-Op Assessment
Records preoperative anesthesia evaluation, including the reason for surgery, medical and medication history, airway and physical examination, relevant studies, ASA class, anesthetic and pain plans, consent, and perioperative considerations.
Surgeon · Note
Audiology Consultation Note
Documents an audiology consultation, including hearing concerns and their daily impact, relevant history, ear and cranial nerve examination, audiologic test results, assessment, counseling, referrals, and follow-up.
Audiologist · Note
Behavioral Therapy Progress Note
Documents a behavioral therapy consultation, including presenting concerns and functional effects, psychiatric and medical history, mental status, relevant examination and screening, assessment, therapy goals, safety planning, and follow-up.
Behaviour Therapist · Note
Brief SOAP Note
Uses concise S, O, A, and P sections to capture the visit reason and relevant history, objective findings or completed investigations, active issues with reasoning, and management steps. It prompts for brevity while retaining follow-up and return precautions.
All Specialties · Note
Cardiology Consult
Records a cardiology consultation, including referral and presenting history, relevant medical and social background, examination, cardiac investigations, and an assessment with corresponding management steps.
Cardiologist · Note
Cardiology Consultation Note
Documents a cardiology consultation, including symptom history, cardiac and general background, medications and allergies, examination and investigations, and an assessment with corresponding treatment, testing, and follow-up plans.
Cardiologist · Note
Cardiothoracic Surgery Consult
Documents a cardiothoracic surgical consultation, including presenting history, medical and social background, examination, investigations, and assessment with a proposed surgical or medical plan.
Cardiothoracic Surgeon · Note
Child Psychiatry Consultation
Documents a child or adolescent psychiatric consultation, including symptom history, psychiatric and medical background, family and school context, mental status, risk assessment, and care plan.
Child And Adolescent Psychiatrist · Note
Chiropractic SOAP Note
Documents musculoskeletal symptoms and relevant history, examination findings, functional assessment, treatment, response, and follow-up. Sections cover subjective history, objective findings, assessment, plan, interventions, evaluation, and additional notes.
Chiropractor · Note
Chronic Pain Consult Note
Documents a chronic pain consultation, including pain history, prior treatment, medical and social context, examination, investigations, and an issue-based assessment and plan.
Chronic Pain Specialist · Note
Cognitive Behavioral Therapy Note
Documents a CBT consultation, covering presenting symptoms and goals, psychiatric and medical context, social history, mental status, formulation, and a therapy plan.
Cognitive Behavioral Therapist · Note
Colorectal Surgery Consult Note
Documents a colorectal consultation with bowel symptom history, medical and surgical background, review of systems, examination, investigations, and an issue-based treatment plan.
Colorectal Surgeon · Note
Comprehensive Geriatric Note
Captures a comprehensive geriatric assessment, including medical history, medications, habits, geriatric review of systems, function, social context, examination, cognitive testing, investigations, and recommendations.
Geriatrician · Note
Consult Note
Provides a general consultation format for a focused history, relevant medical and social context, examination, completed investigations, and an assessment and plan when supplied.
All Specialties · Note
Coroner Report Note
Documents a postmortem examination, including circumstances of death, external and internal findings, ancillary studies, cause and manner of death, and comments on pending work.
Coroner · Document