It’s the same equation for any kind of documentation:

Poor structure + Poor consistency = chaos.

Clinical social worker, Beth Rontal (AKA the Documentation Wizard) wrote about the striking resemblance between clinical notes and dirty dishes.

Rontal says that they both:

• Start as a mess
• Are never-ending repetitive tasks
• Are easy to put off
• Are as necessary as they are tedious.

But just like dishes, notes matter.

That's where clinical note templates come in.

A good note template saves time and cuts through the mental clutter after each session.

Why use clinical note templates

Clinical documentation isn’t the time to reinvent the wheel — or test your creative writing skills.

With clinical note templates, it becomes easier to cut out the fluff and self-edit. You get:

• Efficiency: Speed up documentation by helping you focus on essential information and cut down on mental fatigue
• Consistency: Provide a structure that keeps your notes complete and easy to read.
• Compliance: Standardize your notes in alignment with legal and insurance requirements so you can protect your patients and all care team members.
• Happier patients: Find a sweet spot for your notes that both simplifies care team coordination while giving patients themselves adequate insight into their journey with you.

But of course, clinical note templates aren’t one-size-fits-all.

The key is finding or customizing one that matches your specialty, preferred workflows, and the needs of your employer or medical institution.

Want your templates to actually fit the way you work?

You don’t have to settle for rigid formats or spend time building one from scratch. With Instant Templates, you can now upload or paste in a sample note — like one from your EHR or a past visit — and Freed will instantly generate a Learned Template for you. No more building from scratch. Just upload and go. It works especially well with familiar formats like SOAP.

The Freed template library is a practical starting point. Choose a format that’s close to your setting, then adjust it to match your workflow. As you make edits, Freed’s Auto-laearn feature refines your template in the background, picking up on your structure, phrasing, and preferences so your notes stay consistent without extra effort.

9 clinical note templates & examples

Every clinical note has a purpose, each geared toward helping clinicians capture the right information in different settings.

Here’s a breakdown of the most common types:

1. Progress notes

Progress notes document a patient’s status and response to treatment.

They come in many formats — with the most popular ones being the SOAP, BIRP and DAP note formats. These notes provide a complete overview of a patient’s interaction with care team members, so balancing brevity and comprehensiveness is key.

When do you use progress notes?

Different progress note templates help different healthcare environments.

The most widely used format, SOAP notes, is used in all medical, therapy, and social work settings. But others can be tailored for specific purposes — like the BIRP format for behavioral health cases.

Progress note template

Download this free progress note template today.

2. History & Physical (H&P) notes

H&P notes help physicians, physician assistants, and nurses summarize a patient’s medical history and physical exam findings. These notes help kick off diagnosis and treatment planning by offering care teams a detailed look at a patient’s current condition.

When do you use H&P notes?

These notes are primarily used in hospitals, primary care, and specialty clinics when admitting new patients or conducting comprehensive medical evaluations.

H&P note template

Download this free H&P clinical note template.

3. Discharge summaries

Discharge summaries summarize important information captured during a patient’s hospital stay — like their diagnosis, treatment, and progress during that period a team.

A discharge summary also contains instructions for post-discharge care to ensure a smooth transition over to caretakers or other healthcare providers.

When do you use discharge summaries?

Discharge summaries are required when a patient is discharged from a hospital, rehab center, or skilled nursing facility to ensure continuity of care.

Discharge summary note template

Download this free clinical note template.

4. Consultation notes

Consultation notes contain the findings and recommendations of a specialist after evaluating a patient at the request of another provider.

These notes guide treatment decisions, align decision-making, and ensure proper continuity of care when multiple healthcare providers are involved.

When do you use consultation notes?

These notes are needed when a patient is referred to a specialist for further evaluation. They are commonly used in specialty clinics, hospitals, and multidisciplinary care settings where multiple providers collaborate on a patient’s treatment plan.

Consultation note template

Download this free consultation note template.

5. Prerounding notes

Prerounding notes provide a quick summary of a patient’s overnight status, lab results, and any outstanding issues.

These notes help students, interns, and junior clinicians prepare for patient discussions and streamline communication with attending physicians.

When do you use prerounding notes?

These notes are used in hospital inpatient settings before morning rounds or formal rounds by medical students, residents, and interns.

Prerounding note template

Download this new template for Prerounding.

6. Operative notes

Operative notes outline the details of a surgical procedure, including the techniques used, intraoperative findings, and post-operative care instructions. Operative notes are typically written by surgeons but are sometimes co-signed by assistants, anesthesiologists, or surgical residents.

When do you use operative notes?

These notes are used in operating rooms, surgical centers, and hospitals immediately following a surgical procedure.

Operative note template

Download this free operative note template.

7. Procedure notes

Procedure notes document the details of non-surgical procedures — such as biopsies, endoscopies, catheter placements, or injections.

They ensure accurate record-keeping of minor procedures by capturing information such as the reason for the reason for the procedure, methods and equipment used, patient response and side effects, and post-procedure care.

When do you use procedure notes?

These notes are used in hospitals, outpatient clinics, and primary care settings immediately after performing a medical procedure.

Procedure note template

Download this procedure note template for medical treatment.

8. Nursing notes

Nursing notes (sometimes called a patient or client report) track:

• Patient assessments
• Interventions
• Responses to care

All during a shift. These ensure continuity between nurses and other healthcare providers to accurately track patient progress over time.

These notes can also follow standard progress note formats such as SOAP, DAP, and PIE — some teams call them nursing progress notes for exactly that reason.

When do you use nursing notes?

These notes are used in hospitals, long-term care facilities, and home health settings to document ongoing nursing care.

Nursing note template

Download this new template for patient client reports.

9. Psychotherapy notes

Psychotherapy notes, also called process notes, are private reflections or observations that mental health professionals after a session.

Unlike progress notes, they are not part of official medical records and cannot be used for insurance or legal purposes.

When do you use psychotherapy notes?

These notes are used by psychologists, counselors, and social workers in mental health for personal tracking of therapy sessions.

As they’re intended for private use, therapists can improve client care through deep, detailed reflections without having to worry about reviews from external parties.

Psychotherapy note template

Download this new template for mental health practitioners.

Clinical note formats: SOAP, DAP & BIRP

Most progress notes get written in one of three formats. Here's each one broken down, with its own downloadable template. For a deeper comparison of when to use DAP over SOAP, see our DAP notes guide and SOAP vs. DAP notes breakdown.

SOAP notes

You write a SOAP note with the chronological flow of your patient interactions. You'll start by documenting the issue your patient presents to you before moving on to your own assessment and recommendations.

Subjective

This section is for you to record patient-reported symptoms, concerns, or reason for the visit. Listen actively to your patient. You can include details like when their symptoms began, the severity of symptoms, and related triggers or medical history.

• Example: "The patient says he has been feeling very tired and having headaches every morning."

Objective

In this section, you'll include measurable or observable data such as lab test results, vital signs, or physical observations. Remember to list observations down in the right order.

• Example: "The patient's blood pressure measured 145/90. The patient was observed rubbing his temples during the exam."

Assessment

You'll then provide your clinical evaluation or diagnoses based on the subjective and objective data. You can record your clinical impressions if a formal diagnosis isn't available yet.

• Example: "Stress-induced tension headaches. No signs of neurological deficits."

Plan

Finally, lay out actionable next steps for treatment or follow-up care, including the need for referrals or additional tests. Be sure to include specific timelines for any action or goal.

• Example: "Recommend stress management techniques and a follow-up in two weeks. Prescribe acetaminophen for headache relief as needed."

SOAP note template

DAP notes

DAP notes are more concise than SOAP notes, focusing on information that can be immediately analyzed and acted upon. For this reason, you'll start DAP notes with data and observations before clearly interpreting that data into a plan of action.

Data

You'll record measurable data such as lab test results, vital signs, or physical observations. Unlike SOAP notes, refrain from adding subjective input or narrative details.

• Example: "Patient reports difficulty sleeping (2-3 hours per night) and loss of appetite after a recent car accident. Pulse recorded at 102 bpm during the session."

Assessment

In this section, you'll summarize your clinical evaluation based on the data presented above.

• Example: "Patient is presenting with symptoms consistent with acute stress disorder following a traumatic event."

Plan

Finally, you'll clearly outline your immediate next steps for a patient's treatment or follow-up care.

• Example: "Provided grounding exercises to reduce distress and demonstrated techniques during the session. Referred to trauma counselor for evaluation within one week."

For the full DAP breakdown, examples by specialty, and a dedicated download, see our DAP notes guide.

BIRP notes

BIRP notes are all about tracking patient behavior and responses rather than data. Here's how you approach writing them.

Behavior

Describe any behavior or expressions you observe during a session. Focus on behavior relevant to why your patient is seeing you during this session.

• Example: "Patient appeared withdrawn, avoided eye contact, and spoke in a soft voice when discussing recent family conflicts."

Intervention

Document the techniques used during the session to help manage symptoms.

• Example: "Facilitated discussion on family communication strategies and introduced role-playing exercises."

Response

Explain how the patient reacted to the intervention. You can note any changes in their behavior, mood, or engagement throughout the session.

• Example: "Patient engaged in role-playing exercises and expressed feeling more confident about addressing conflicts."

Plan

Outline your next steps in the treatment process.

• Example: "Focus on practicing communication strategies during next session. Schedule family counseling session within two weeks."

Progress notes by care setting

Some settings need their own structure on top of the standard formats above. Here are three that come up often, each with its own template.

Prerounding note template

In a prerounding note, you'll track basic patient details to monitor their hospital course and status. You'll record key identifiers such as:

• Admitting diagnosis
• Pertinent past medical history
• Length of stay (LOS)

This helps provide context for their clinical status and treatment trajectory.

Subjective

Include overnight events, patient-reported symptoms, or updates from nursing staff. Focus on changes in pain, appetite, sleep, or new concerns.

• Improved appetite
• Intermittent nausea overnight
• No new complaints

Objective

Record measurable data, including vital signs, lab results, and imaging updates. Note significant changes or abnormalities.

• Vitals: HR 88, BP 120/80, RR 16, O2 sat 98% on RA
• Labs: WBC ↑ to 12.5 (prev. 10.2)

Assessment & plan

Summarize your clinical impression and outline the next steps for management, including treatments, medication adjustments, and pending tests.

• Status: Stable overnight
• Plan: Continue IV fluids, advance diet as tolerated, repeat CBC tomorrow

To-dos

List any follow-ups, consults, or documentation tasks before rounds — pending blood cultures, PT/OT evaluation recommendations, and anything else that needs an answer before you're on the spot.

Prerounding note template

Two layouts available: Portrait with 1 patient per page, or Landscape with 3 patients per page.

OT progress note template

Occupational therapy (OT) progress notes focus on helping patients perform meaningful activities in their daily lives. These notes track functional changes over time — think grooming, dressing, cooking, or handwriting.

Here's a simple structure for an OT progress note:

Subjective

Patient reports frustration with dressing tasks and fatigue during morning routines.

Objective

Observed patient putting on a button-up shirt using adaptive technique. Required moderate verbal cueing and minimal physical assistance. Coordination improved from last session.

Assessment

Progressing with fine motor skills. Still dependent for some dressing tasks but showing improved initiation and sequencing.

Plan

Continue ADL-focused sessions 2x/week. Introduce new dressing aids and begin training next session.

OT progress note template

PT progress note template

Physical therapy (PT) notes are movement-focused. These notes are often a mix of pain management, strength, range of motion, and mobility improvements.

Here's a quick example:

Subjective

Patient reports decreased pain during walking and improved sleep since last session. Rates pain 3/10 (down from 6/10).

Objective

Gait analysis: mild limp remains but stride length improved. Left hamstring strength tested 4/5 (previously 3/5). Completed all exercises with good form and no rest breaks.

Assessment

Patient demonstrating functional gains in strength and endurance. Mild compensations still present but improving.

Plan

Advance therapeutic exercises. Introduce single-leg balance work. Continue 3x/week sessions and reassess ROM next week.

PT progress note template

Templates by specialty

A few specialties search for their own version of these templates often enough that they deserve a direct answer. None of these need a brand-new format — they're the formats above, applied with specialty-specific judgment.

Social work progress notes template

Social workers most often reach for either the standard SOAP format (use the progress note template above) or DAP, which tends to fit fast-paced caseloads better since it skips the separate subjective/objective split. Whichever format your agency requires, the same documentation basics apply: primary concern, intervention, and a plan tied directly back to the client's treatment goals — not just "patient advised to..." with no rationale attached.

Therapist / behavioral health progress notes template

Therapists and behavioral health clinicians split fairly evenly between DAP and BIRP, depending on whether the priority is documenting data (DAP) or behavior and response to intervention (BIRP) — both are broken down with examples and downloads above. For private, non-billable session reflections rather than the official clinical record, see the psychotherapy note template further up this page.

Orthopedic progress note template

Orthopedic visits are a strong fit for standard SOAP — use the SOAP template above as your base. The detail that matters most in an ortho note is objective, measurable tracking from visit to visit: range of motion in degrees, strength graded on the standard 0–5 scale, and any imaging findings referenced by date, so a change in status is obvious at a glance rather than buried in narrative.

How to write a clinical note

Format changes by specialty and setting. These five steps don't:

1. Document as close to the encounter as possible. The longer the gap, the more the note relies on memory instead of what actually happened.
2. Separate what you observed from what was reported. Subjective vs. objective is the backbone of nearly every format on this page, not just SOAP.
3. Tie every assessment back to a specific finding. "Patient advised to increase activity" says nothing on its own — connect it to the concern or goal that prompted it.
4. Stay factual and specific. "Patient is doing better" is weaker documentation than "pain decreased from 7/10 to 3/10." Skip personal opinions and unverified assumptions entirely — these are legal documents.
5. Close with a plan, every time. Whoever reads this note next — a colleague, an insurer, you in six months — should know exactly what happens next and by when.

Pick a format, stay consistent with it across a patient's chart, and use the templates above so you're never starting from a blank page.

Customizing your clinical note template

Your clinical note templates are only as useful as how you use them. The key? Small tweaks to match your workflow:

Here are a few tips:

1. Keep it short & structured

Use your format and stick to it, and only add relevant information.

“I think there are three important acronyms for note taking: DAP - Data, Assessment, Plan SOAP- Subjective, Objective, Assessment, Plan And KISS Keep It Short and Simple,” Reddit user MarcusArtorius

2. Adapt to your setting

Some notes need details, others just the essentials. A therapy progress note template looks different than a treatment plan.

3. Use bullet points

Faster to write, easier to read.

“Bullet points. Seriously. Use templates to sort the sections with the bullet points ready to go underneath each header. — Reddit user Freemind323

4. Save common phrases

Dotphrases in your EHR can be a lifesaver.

5. Duplicate & edit

No need to rewrite every note—just update the essentials.

"I import the old note and change/update anything that isn't accurate for that session... Fresh writing is probably 3-5 sentences per note, more if something complex is happening." — Reddit user, AntiqueOwl1662

How to choose the right clinical note template

Beyond the adjustments you can make to your note-taking process, you also need to consider the template itself.

The last thing you want to do is spend an extra hour reentering or reformatting your notes because you used a template that didn’t exactly fit the needs of your care team or employer.

Here are some best practices to help you make an informed decision:

1. Match the template to your workflow: Choose a template that aligns with your day-to-day routines and habits. For example, you can opt for more structured templates if you typically have a heavier workload or less structured ones if you’re already familiar with note-writing and have a preferred writing style in place.
2. Be consistent with your team: If you’re coordinating care with a team or multiple providers, opt for a template that’s aligned with the requirements or recommendations of everyone you work with.  It should include mandatory details for your employer’s legal, insurance, and reimbursement needs.
3. Evaluate customization options: Look for templates that allow easy modifications so you can tailor sections based on your preferences and patient needs — better yet, if it’s automated. AI notetakers like Freed, for instance, learn from your edits to transcriptions and delivers customized notes that match your style and format.
4. Test and iterate: If a template isn’t working, don’t wait to adjust or switch to a different format! Try out a template for a few weeks and gather feedback from your team.

More templates to pair with your clinical notes

Need patient-facing notes too? Browse our patient notes templates. Track ongoing care with the progress note template. Or skip the manual work with AI scribe templates and answers to common Freed template questions.

Put clinical note templates to action

Clinical notes don’t have to be a source of frustration. The right template can turn documentation from a chaotic mess into a streamlined, structured process that saves time and mental energy.

Whether you’re jotting down progress notes, discharge summaries, or mental health reflections, a well-chosen template helps you stay efficient, compliant, and focused on what matters.

And if you want to take things a step further, AI-powered tools like Freed can adapt to your style, making note-taking even more effortless.

At the end of the day, documentation should work for you — not the other way around.

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