Clinical notes are no one's favorite part of the job—but they're more than cogs in the admin wheel.

Progress notes help us shape treatment, build the patient chart, and even educate our patients on their health; a recent study found that two out of three patients are more likely to adhere to their medication after reading their doctor’s notes.

But knowing why we need progress notes doesn't make them any more fun to do.

While I can't say you'll ever be psyched to write notes, we've rounded up some examples, tools, and note templates to make the struggle a little less real.

What is a clinical note?

The baseline definition of a clinical note is a written record a patient visit.

This actually has a fascinating history. The clinical notes of today came from Dr. Larry Weed, who invented the SOAP note format.

Being both a doctor and a scientist, Dr. Weed realized that the clinical documentation process was a really a whole lot of disorganized thinking.

Simply put, doctors weren't being taught how to use progress notes as a way to collect objective data. This made way for the electronic medical record (EMR software) that we know and tolerate today.

Thanks to his efforts, our progress notes help us build a patient's chart.

And now, there are several different types of progress notes that we can use based on our specialty, technique, and treatment goals.

Why are clinical notes important?

Clinical notes play a crucial role in patient care

According to Dr. Weed himself, a good clinical note is the backbone of continuity of care.

"We’re really not taking care of records; we’re taking care of people. . . . This record cannot be separated from the caring of that patient. . . . This is the practice of medicine.” — Dr. Larry Weed, Founder of SOAP notes

That's because clinical documentation is a reference point for healthcare professionals to:

• Track progress
• Make informed decisions about a treatment plans
• Communicate with other providers involved in follow-up care

And when shared with patients, progress notes act as a bridge from medical jargon to person-centered care. According to the American Medical Association, patients who see their progress notes:

• Are more likely to remember their visits
• Better adhere to medication
• Have greater trust in healthcare professionals
• Are more involved in their treatment goals

Types of clinical notes

A progress note is like a snapshot in time. It's a focused record of patient encounter—whether you're monitoring daily progress during a hospital stay or tracking a weekly therapy session.

"They let you document a patient’s experience in a way that makes it easier to find patterns, track changes, and communicate with other providers." — Dr. Sean Ormond, Atlas Pain Specialists

Depending on your specialty or use case, you might include different details or emphasize various aspects of the note.

The most popular types of clinical note formats are:

• SOAP (Subjective, Objective, Assessment, and Plan) sometimes in ASPO order
• DAP (Data, Assessment, Plan) notes
• BIRP (Behavior, Intervention, Response, Plan) notes

Examples of Clinical Notes

In the setting of drafting clinical notes, let's use the SOAP format as a reference for our clinical note examples.

I've categorized them into the various possible visit scenarios:

1. Primary care visit example

‎Using the SOAP format, here's what a clinical note for a primary care visit for a new complaint (e.g., chest pain) should look like:

Subjective: The patient complains of chest pain that started earlier today. They rate the pain as a 7/10 and describe it as a sharp, stabbing sensation. They deny any previous history of similar symptoms.

In the Subjective section shown above, a SOAP note typically includes a detailed description of the patient's symptoms and their personal history. This provides important context for the healthcare provider to understand the current complaint.

Also, having clear documentation of this section would provide you with a fuller picture if the patient ever returns for a follow-up visit.

Objective: Vital signs are normal (130/80mmHg). Physical exam reveals tenderness upon palpation in the chest area. No other abnormalities noted.

For the Objective section, you can include any clinical observations and physical examinations. Try to be detailed but concise.

Assessment: Musculoskeletal injury causing chest pain.

Next, for the Assessment, you will be using your knowledge and expertise to make a preliminary diagnosis based on the information gathered from the patient's symptoms and physical exam.

In this example, you can state your diagnosis in a short sentence for brevity.

Plan: Recommend physical rest and aspirin for pain management. Follow up in two weeks if symptoms persist or worsen.

Lastly, in a primary visit, you can also include any preventive measures or lifestyle changes that may help the patient recover faster or prevent further injury.

In this case, it would be important to remind the patient to avoid activities that may strain the chest area and to follow these recommendations until the follow-up visit.

2. Mental health follow-up example (anxiety and depression)

‎In this follow-up mental health note, the focus is on tracking the patient’s progress with their treatment goals, including:

• Therapy sessions
• Coping strategies
• Medication Management

This therapy progress note should provide a clear picture of the patient’s current mental health status and guide the next steps in their care.

The Subjective section captures the patient’s reported experiences, emotions, and feedback on their progress. Include any details about adherence to therapy or medication, as well as specific challenges or successes.

Subjective:

• Patient reports persistent feelings of worry and tension, particularly at night, rated at 5/10 on a distress scale.
• Reports improved adherence to mindfulness practices but struggles with maintaining focus during exercises.
• Noted a slight decrease in frequency of panic attacks (previously daily, now 2-3 times per week).
• Reports adherence to prescribed medication but mentions mild side effects, including occasional drowsiness.

In the Objective section, describe observable behaviors, physical presentation, and any measurable data (e.g., psychometric scores or therapy progress markers). This is based on your observations and any tools or assessments used during the session.

• Patient presents as alert and oriented, with improved posture and eye contact compared to the last session.
• Affect is slightly brighter, though mood remains subdued.
• Psychometric assessment completed during the session indicates a reduction in anxiety scores from severe to moderate.
• No reported self-harm ideation or recent major life stressors since the last appointment.

For the Assessment, include a short description of the patient’s current status and their progress with treatment. Since no new diagnosis is required, this section focuses on evaluating the effectiveness of interventions and any notable changes.

• Patient demonstrates moderate improvement in anxiety symptoms and slight progress with depression.
• Increased adherence to mindfulness and therapy techniques indicates engagement with the treatment plan.
• Mild medication side effects (drowsiness) require monitoring.

In the Plan section, outline the next steps for the patient’s care. This includes adjustments to therapy, recommendations for coping strategies, any changes to medication, and plans for follow-up. Emphasize the importance of adherence to these strategies for continued progress.

• Continue current medication dosage; discuss side effects with prescribing physician if they persist.
• Introduce journaling exercises to explore nighttime stressors and support emotional processing.
• Maintain weekly CBT sessions to further address anxiety triggers and build coping strategies.
• Encourage consistent mindfulness practice, with a focus on shorter, guided meditations to enhance focus.
• Schedule follow-up appointment in two weeks to reassess progress and adjust the plan if needed.

3. Specialty consultation example

‎For a specialty consultation, you'll likely need to gather more detailed information about the patient's condition and medical history.

Here's what a progress note will look like for a dermatology consult:

Subjective: Patient presents with a rash on their arms and legs that has been present for the past week. They report itching and discomfort, but no pain. Patient states they have not changed any skincare products recently.

This will be where you'll note down all the patient's chief complaints and when was its onset.

Objective: Multiple raised red patches were noted on both arms and legs. Patches appear to be slightly swollen and warm to the touch.

Note down any physical examination observations, and try to be descriptive without being too lengthy.

Assessment: Allergic reaction or contact dermatitis.

For the Assessment, provide a concise diagnosis for clarity. You may add a short description if more details are required.

Plan: Recommend avoiding any potential irritants or allergens that may have caused the rash. Topical corticosteroid cream to alleviate itching and inflammation was given. A follow-up appointment in two weeks to monitor improvement.

For the Plan section, you can include any possible courses of action. This can vary across patient conditions across different specialties.

This could include:

• Medication
• Occupational therapy
• Surgery

You may also need to perform specialized tests or procedures in order to make a proper diagnosis.

3. Post-surgery follow-up

‎In a post-surgery clinical note, you'll be building upon the medical charts of previous notes.

In this note, be sure to include any updates on the patient's recovery and healing process.

Here's a SOAP note example of a shoulder replacement post-surgery:

Subjective:

• Patient reports mild pain and discomfort in the shoulder, rated at a 3/10 on the pain scale
• No significant changes in symptoms since last follow-up appointment two weeks ago
• Reports adherence to post-surgery care instructions, including physical therapy exercises

Objective:

• Shoulder incision healing well with no signs of infection or abnormal scarring
• Range of motion has improved compared to previous visit, but still limited due to surgical precautions
• Physical therapy sessions have been progressing well with increased strength and flexibility noted

During the post-surgery consult, you should do a re-examination of the surgery site, as well as the overall body function.

If there were any unexpected findings or results during the surgery, make sure to provide an explanation and discuss how it may affect the patient's future treatment plans.

Also, do mention any potential complications or side effects that may have arisen since the surgery. It is important to closely monitor the patient during this time and address any concerns or issues that may arise.

Assessment:

• Patient is recovering well from shoulder replacement surgery
• Mild pain and discomfort expected at this stage of recovery

For Assessment, the diagnosis is "post shoulder replacement." Include a short description of the patient status and their recovery progress.

Plan:

• Patient will continue with prescribed pain medication as needed
• Physical therapy sessions will continue twice a week for the next 4 weeks, then decrease to once a week
• Patient advised to avoid strenuous activities and heavy lifting until further notice
• Close monitoring for any potential complications or side effects from surgery
• Next follow-up appointment scheduled in 1 week to assess progress and make any necessary adjustments to treatment plan

In the Plan section, discuss the recommended post-surgery care plan, including any medication changes or physical therapy exercises. Emphasize the importance of following these instructions for optimal recovery.

You'll also need to address any follow-up appointments or tests that may be necessary in order to track the progress of the surgery and ensure proper healing.

Tips for Writing Clinical Notes

Already thinking of all the extra work you'll need to put in for clinical paperwork? Here are some tips to help you write them better and faster:

Accuracy

Accuracy is key—make sure to document all relevant information and avoid any mistakes or misunderstandings. If any mistakes are made, it can have serious consequences for the patient's treatment. This may lead to legal issues or even harm to the patient.

Clarity

When taking down notes, you'll want to make sure that they aren't vague and subjective. For example, a diagnosis should be precise and not just a general statement. This will help provide clarity for the patient's condition and treatment plan.

Brevity

Brevity is important in clinical notes as well, especially when it comes to progress or follow-up notes. You don't want to spend too much time writing lengthy paragraphs that could easily be summarized in a few sentences. Stick to the key information and avoid unnecessary details.

Still struggling to keep these tips in mind while taking clinical notes?

AI scribes can automatically transcribe your conversations with patients, followed by generating formatted SOAP notes. Did I also mention that it can learn from your style? This makes it easily implemented across specialties.

Final Thoughts

Remember, clinical notes are crucial. They serve as a comprehensive record of the patient’s history, progress, and treatment plan.

Whether you’re in a primary care clinic, a mental health practice, or a specialized medical field, taking the time to craft effective clinical notes is an investment with major pay off.

Freed is the most clinician-focused company in the world. Try our AI scribe for free.