A clinical note template is a pre-structured document that guides clinicians through recording a patient encounter in a consistent, complete format. Below, you'll find ready-to-use clinical note templates you can copy directly from this page or download as a PDF, plus a fully worked example so you can see exactly what a finished note looks like.

You can download the PDF version here.

Key Takeaways

• A clinical note template standardizes documentation: It ensures every encounter captures the same essential elements (chief complaint, history, exam findings, assessment, and plan) no matter who writes the note.
  
  

• Templates cut documentation time, but don't eliminate it: Research published in JAMIA shows clinicians still spend a substantial share of their workday on EHR documentation, even with structured formats.
  
  

• Match the format to the visit: SOAP works for most routine encounters, while initial assessments and complex cases need a more comprehensive problem-based structure.
  
  

• AI can fill the template for you: Tools like Sully's AI medical scribe listen to the visit and generate a complete note in your template automatically; you just review and sign.

Free Clinical Note Template

This general-purpose clinical note template works for most outpatient encounters. Copy it straight into your EHR, or download the PDF version here.

CLINICAL NOTE

Patient Name:                    DOB:

Date of Visit:                   Provider:

Chief Complaint:

HISTORY OF PRESENT ILLNESS

[Onset, location, duration, character, aggravating/relieving

factors, timing, severity. Relevant context and pertinent

positives/negatives.]

REVIEW OF SYSTEMS

Constitutional:        Cardiovascular:

Respiratory:           Gastrointestinal:

Musculoskeletal:       Neurological:

Skin:                  Psychiatric:

[All other systems reviewed and negative unless noted.]

PAST MEDICAL HISTORY

Medications:

Allergies:

Surgical History:

Family/Social History:

PHYSICAL EXAMINATION

Vitals: BP ___ | HR ___ | RR ___ | Temp ___ | SpO2 ___

General:

[Focused exam findings by system]

ASSESSMENT & PLAN

1. [Problem 1 — assessment and clinical reasoning]

   Plan: [Investigations, treatment, referrals, patient education]

2. [Problem 2]

   Plan:

Follow-Up:

Provider Signature:              Date:

This problem-based structure keeps the note scannable: any covering clinician can find your reasoning and next steps in seconds. If you mostly write follow-up notes rather than full evaluations, a leaner structure like our progress note template may fit better.

Clinical Note Example (Filled In)

Templates make more sense when you see one completed. Here's the same template filled in for a routine primary care visit.

CLINICAL NOTE

Patient Name: J.M. (example)        DOB: 03/14/1968

Date of Visit: 08/17/2026           Provider: Dr. A. Rivera, MD

Chief Complaint: Persistent cough x 3 weeks

HISTORY OF PRESENT ILLNESS

58-year-old male presents with a dry cough for 3 weeks, worse at

night. No fever, chills, or hemoptysis. Started lisinopril 6 weeks

ago for hypertension. No recent travel or sick contacts. Denies

shortness of breath, chest pain, or wheezing.

REVIEW OF SYSTEMS

Constitutional: No fever, no weight loss.

Respiratory: Dry cough as above; no dyspnea.

Cardiovascular: No chest pain, no palpitations.

All other systems reviewed and negative.

PAST MEDICAL HISTORY

Medications: Lisinopril 10 mg daily, atorvastatin 20 mg daily

Allergies: NKDA

Surgical History: Appendectomy (1994)

Social History: Never smoker; occasional alcohol.

PHYSICAL EXAMINATION

Vitals: BP 132/84 | HR 72 | RR 14 | Temp 98.2°F | SpO2 98%

General: Well-appearing, no acute distress.

Lungs: Clear to auscultation bilaterally. No wheezes or crackles.

ENT: Oropharynx clear, no postnasal drip visualized.

ASSESSMENT & PLAN

1. Chronic cough, likely ACE-inhibitor induced.

   Plan: Discontinue lisinopril; start losartan 50 mg daily.

   Cough expected to resolve within 1–4 weeks.

2. Hypertension, controlled.

   Plan: Continue lifestyle measures; recheck BP at follow-up.

Follow-Up: 4 weeks, sooner if cough worsens or new symptoms.

Notice what makes this note effective: every problem has explicit reasoning and a concrete plan, pertinent negatives are documented, and a colleague could pick up care tomorrow without a phone call.

Common Clinical Note Formats Compared

Not every encounter needs the same structure. Here's how the most widely used clinical note formats compare:

SOAP remains the default for good reason, it's universally understood and maps cleanly to clinical reasoning. If that's your daily format, Sully's AI SOAP note generator produces structured SOAP notes automatically from the visit conversation.

What Should a Clinical Note Template Include?

Regardless of format, a complete clinical note template should prompt you for:

• Patient identifiers and visit details: Name, DOB, date, and provider; the basics that make the note legally valid.
  
  

• Chief complaint and HPI: The patient's reason for the visit in their own words, followed by a structured history.
  
  

• Objective findings: Vitals, exam findings, and any point-of-care results.
  
  

• Assessment with reasoning: Not just a diagnosis, but why, this is what protects you medico-legally and helps colleagues follow your thinking.
  
  

• A concrete plan: Orders, prescriptions, referrals, patient instructions, and follow-up timing.

Pro tip: The single most common weakness in clinical notes is an assessment that states a diagnosis without reasoning. A good template forces one line of clinical rationale per problem.

How to Choose the Right Clinical Note Template

1. Start from your visit mix. If 80% of your encounters are follow-ups, optimize for a fast progress-note format and keep a comprehensive template for new patients and complex cases.

2. Check it against your best note. Pull up a note you're genuinely proud of, then ask whether the template you're evaluating would produce something as good. If it wouldn't, keep looking or customize.

3. Keep your library small. Most clinicians need only three to five templates: an initial assessment, a progress note, a procedure note, and one or two specialty-specific formats.

4. Edit ruthlessly. No template survives contact with real practice unchanged. Delete sections you never fill in, an empty field in every note is noise, not thoroughness.

Frequently Asked Questions

What is a clinical note template? 

A clinical note template is a structured document with predefined sections, such as chief complaint, history, exam, assessment, and plan, that guides clinicians through documenting a patient encounter completely and consistently. It reduces the cognitive load of deciding what to write and ensures nothing essential is missed.

What should be included in a clinical note? 

At minimum: patient identifiers, date of service, chief complaint, relevant history, objective findings, an assessment with clinical reasoning, and a plan with follow-up. Specialty and payer requirements may add elements like time spent or medical decision-making complexity.

What's the difference between a clinical note and a SOAP note? 

A SOAP note is one specific format of clinical note, organized into Subjective, Objective, Assessment, and Plan sections. "Clinical note" is the broader category that includes SOAP, DAP, BIRP, H&P, and problem-based formats.

Are clinical note templates free to use? 

Yes, the templates on this page are free to copy or download as a PDF, with no signup required. Note formats like SOAP are industry standards, not proprietary structures.

Can AI write clinical notes from a template? 

Yes. AI medical scribes like Sully listen to the patient visit (with consent), then generate a complete, structured note in your chosen template within seconds. The clinician stays in control, every AI-generated note is reviewed and signed by the provider before it enters the record.

How do I customize a clinical note template for my specialty? 

Start with a general template, then add specialty-specific sections (e.g., mental status exam for psychiatry, functional assessment for physical therapy) and remove fields you never use. With Sully, you can create custom templates once and every AI-generated note will follow that structure automatically.

Sources

1. JAMIA (via PubMed Central): Research on clinician time spent in EHR documentation. https://pmc.ncbi.nlm.nih.gov/articles/PMC8290305/