For most clinicians, patient documentation has become a daily mental marathon that extends well beyond clinic hours.

Any night spent charting is one night too many.

If preparing patient notes is draining your mental battery, simply use patient note templates.

Be like Kevin:

I’ve curated nine plug-and-play patient note templates to speed up clinical documentation and reduce the brainpower spent in the process. Each template is designed to take the headaches out of paperwork.

9 must-have patient note templates for medical documentation

Using templates is a surefire way to reduce your documentation burden. You don’t have to start every patient note from scratch and write repetitive details over and over again.

I’ve curated nine essential clinical note templates for various use cases. 

Learn the best practices for using these templates to streamline your medical documentation process across a patient’s journey. 

1. Patient intake form

Initial patient assessment notes, also known as intake notes, prepare the groundwork for a person’s medical record. 

These comprehensive notes contain the baseline information about a patient’s condition. These details serve as a starting point for treatment plans and clinical decisions in the future.

As a best practice, you can create a standardized intake form for patients to fill out before their first visit. This allows you to reserve your documentation time for clinical impressions rather than basic data collection. 

When it's used

A healthcare professional creates initial patient assessment notes during a patient’s first visit. You have to prepare these notes as a new provider to establish a reference for care plans and treatments in the future. 

What to include

Here are some key details to include in your initial assessment notes template:

• Primary concerns 
• Contact information 
• Patient demographics
• Current medication and allergies
• Social history, including lifestyle and habits
• Preliminary assessment and diagnostic plan

Patient intake form template

2. SOAP notes

SOAP notes, also known as progress notes, allow you to document ongoing patient care with a structured approach. 

SOAP notes follow a universally recognized format—subjective, objective, assessment, and plan. That means a patient’s record will be easily understandable for every healthcare provider they interact with. 

When creating SOAP notes, aim to capture subjective insights in the patient’s own words. You also need to connect subjective and objective findings to support and explain your clinical decisions. 

When it’s used

These progress notes are best used for routine follow-ups and chronic disease management. 

Since SOAP notes work across all specialties, any type of healthcare provider can use these notes to track patients’ conditions over time.

What to include

Here are a few elements to include when writing SOAP notes:

• Subjective: Patient's reported symptoms, concerns, and experiences
• Objective: Measurable data ,including vital signs, physical exam findings, and test results
• Assessment: Clinical impression, diagnoses, and differential considerations
• Plan: Treatment recommendations, medications, referrals, and follow-up instructions

SOAP note template

3. Medical history form

A medical history form gathers essential details about a patient’s past and present health conditions, so you can make informed decisions about treatment and care.

This form acts is a foundation for understanding a patient’s:

• Risk factors
• Allergies
• Chronic conditions
• Previous medical interventions.

Having a standardized medical history form ensures consistency and completeness in patient records while reducing the need for repeated questioning during consultations.

When it's used

A medical history form is typically completed during a patient’s first visit or when updating their health records. It helps clinicians assess risk factors, plan treatments, and coordinate care more effectively.

What to include

A comprehensive medical history form should capture:

• Personal information (name, date of birth, contact details)
• Past medical conditions (chronic illnesses, surgeries, hospitalizations)
• Family medical history (genetic predispositions, hereditary conditions)
• Current medications (prescriptions, over-the-counter drugs, supplements)
• Allergies (medications, food, environmental triggers)
• Lifestyle factors (smoking, alcohol use, exercise habits)
• Vaccination history
• Review of systems (symptoms related to different organ systems)

Free medical history form template

4. Procedure notes

Procedure notes mention the details of the treatment performed on a patient. These notes cover every intervention during the treatment procedure. They include technical aspects, findings, and outcomes of the procedure.

Procedure notes describe the treatment technique with time-stamped steps for complex or lengthy procedures. 

Clinicians also document complications during the procedure with a clear explanation of how they were addressed. You need specialty-specific templates for such patient notes.

When it's used

Procedure notes are used for all kinds of treatments — from minor in-office procedures to major surgeries. Clinicians have to complete these notes immediately for invasive procedures and diagnostic tests. 

What to include

Here are a few essential details to add to a procedure note template:

• Informed consent document
• Pre-procedure assessment
• Procedure name and indication
• Step-by-step description of the technique
• Complications or difficulties encountered
• Post-procedure instructions and monitoring

Procedure note template 

5. Discharge summary notes

Discharge notes provide an overview of a patient’s hospital stay—treatment performed, medicines administered, and similar details. These notes also include a set of instructions for the patient’s recovery after discharge. 

These notes bridge the gap between inpatient and outpatient care. 

Writing clear and actionable information is important for a patient’s caretakers to continue their recovery. Clinicians have to provide simple steps and prepare a follow-up plan for future consultations.

When it’s used

Discharge summary notes are prepared when a patient has to be discharged from a hospital to a different place, like their home or a rehabilitation center. 

Clinicians have to complete discharge summaries within 24 hours to ensure timely communication with follow-up providers.

What to include

Here are some details to add to your discharge summary template: 

• Admission date and principal diagnosis
• Overview of hospital stay 
• Procedures performed and key events
• Discharge diagnoses (primary and secondary)
• Discharge medications with clear instructions
• Follow-up appointments and schedule

Discharge summary note template

6. Consultation notes

Consultation notes capture insights from a specialist’s review of a patient’s reports. 

These notes facilitate communication between two or more healthcare providers about a patient. Such a note includes recommended treatments or questions from one specialist to another.

Since these notes capture different providers’ clinical reasoning, they have to use clear language to avoid any ambiguity. Clinicians should also specify whether they need a one-time consultation or continuous support from another specialist.

When it’s used

Consultation notes are used when a specialist evaluates a patient at another provider's request. 

A clinician can request an evaluation of the diagnoses, procedure considerations, treatment recommendations, and other details. The consulting clinician prepares a note answering this request with detailed insights and recommendations based on their own reasoning.

What to include

Here’s the patient information to cover in your consultation notes template:

• Consultation purpose and request 
• Patient’s medical history and relevant reports
• Assessment and clinical reasoning 
• Detailed recommendations with a clear rationale
• Availability for follow-up questions

Consultation notes template

7. Telephone notes

Telephone notes document remote patient visits over calls, video meetings, or messages. Used for virtual consultations, these notes document all clinical information from a patient-physician interaction. 

Clinicians also need to follow telehealth billing requirements to prepare these notes. 

When it’s used

Telephone notes are subjective and depend on the kind of consultation you have with patients on a call or message. That said, clinicians should prepare these notes when exchanging substantial clinical information such as:

• Prescription changes 
• Follow-up test results 
• Patient concerns and questions
• Pre or post-operative instructions

You should also prepare notes for information related to billing and reimbursements.

What to include

Here are some crucial details that go into a telephone note template:

• Consent form for tele healthcare services
• Verification of patient identity and location
• Primary complaint and focused patient history
• Assessment based on available information

Telephone notes template

8. Emergency department notes

The emergency department notes cover time-sensitive cases and capture all the interventions performed on a patient. These notes also explain the medical decision-making process to highlight the rationale behind each intervention.

It’s best to use a chronological approach to document the progression of care in emergency scenarios. 

Clinicians also prepare these notes to share their risk assessment and reasoning for each step during the procedure. 

When it’s used

Emergency department notes are used to document a patient’s entire visit to the emergency room. These notes cover everything from initial presentation to discharge, admission, or transfer. 

What to include

Here are some essential details to add to emergency department notes:

• Primary concern and focused history
• Timing of key events and interventions
• Critical test results with time of review
• Medical decision-making and risk stratification

Emergency department notes template

9. Mental Health Treatment Plan

Treatment plan or mental health progress notes notes document patient care for psychological concerns. 

These notes have to strictly adhere to privacy considerations and use objective language to describe patient behavior. Clinicians have to avoid judgmental terminology or subjective vocabulary. 

Use these notes to document your risk assessment and substantiate it with specific statements by the patients. 

When it’s used

Behavioral health notes are primarily used during psychiatric evaluations and therapy sessions. 

These notes are also suitable for documenting follow-up visits for chronic disease management. They help in assessing the effectiveness of the prescribed treatment and medication.

What to include

Here are a few elements to add to your behavioral and mental health notes template:

• Risk assessment (suicide, homicide, self-harm)
• Therapeutic interventions used and response
• Progress toward treatment goals
• Medication effects and adherence

Mental health progress treatment plan template

9. Palliative care notes

Palliative care notes, also known as end-of-life care, documents the approach of helping patients manage and live with illness that can’t be cured. It includes recommendations for symptom management to provide continuous support and enhance the quality of life.

Clinicians should use these notes to document patients' goals in their own words whenever possible. You can also add a section to focus on directives for emergency situations.

Since these notes are meant for a patient’s family and caretakers, they have to be clear and easy to understand.

When it's used

Palliative care notes document the care approach for patients with terminal illness. These notes can also be used for patients living under hospice care or going through palliative interventions alongside curative treatment.

What to include

Here are the details to include in your palliative care notes template:

• Advanced care planning instructions
• Symptom management guidelines
• Comfort-focused interventions
• Changes in goals of care over time

Palliative care notes template

Use AI scribes to go beyond the manual busywork of templates

Templates give you a head start, but they still leave you doing the heavy lifting. Freed finishes the job for you — so you don’t have to.

For so many clinicians like you, medical documentation templates aren’t enough. You inevitably have to reserve your mental energy for later to finish charting notes from the day. 

That’s where an AI scribe solution like Freed can turn the tables in your favor.

Freed’s AI scribe automatically documents every patient interaction and creates detailed SOAP notes in a few minutes. 

All you need to do is press the record button when your visit begins and hit stop once the visit ends. Freed will capture the entire conversation and generate accurate notes before the patient even leaves your clinic. Edit and customize these notes to match your style. 

Within minutes, your notes are ready—complete, accurate, and organized exactly how you need them.

What Freed can do for clinicians’ wellbeing 

Instead of getting tied up in templates and manual paperwork, Freed takes away all the busywork to give you:

• Greater mental clarity and flexibility to focus entirely on your patients
• Lower anxiety about unfinished charts at the end of the day
• Freedom to go home when your last patient leaves 

Feels like dropping a 10-lb chart binder you didn’t even know you were carrying. Sign up for Freed to experience it yourself.