Template library

Clinical note templates, free to use

Every template here includes section-by-section guidance and a filled clinical example. Copy them into any EMR, or let ScribeMDPro draft the same structure from the consultation itself.

8 templates

The standard four-part clinical note used across primary care, urgent care and hospital medicine. Subjective, Objective, Assessment and Plan, with the level of detail auditors and colleagues expect.

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A SOAP structure adapted for children: history is taken from a caregiver, weight drives every prescription, and growth, feeding, immunisation status and development belong in the record.

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A musculoskeletal intake structure built around mechanism of injury, objective range of motion, named special tests and a staged conservative-to-operative plan.

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A mental health progress note structured around the mental state examination and an explicit, dated risk assessment — the two elements reviewers look for first.

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Obstetrics & Gynaecology

A routine antenatal review structured around gestational age, maternal observations, fetal assessment and the screening schedule for that visit.

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A remote-consultation note that records the elements payers and regulators require: consent, modality, both parties' locations, and what could not be examined.

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A time-critical ED structure: triage category, focused history and examination, risk score, investigations, reassessment and an explicit disposition decision.

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A problem-oriented review note for long-term conditions, built around control markers, adherence, complication screening and an explicit titration decision.

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Related

Stop retyping the same structure every visit.

ScribeMDPro drafts these templates from the consultation. You review and approve.