Clinical Notes Library
Standard clinical documentation formats used across health professions — SOAP, DAP, BIRP, GIRP, PROC, progress notes, intake notes, and discharge summaries. Generate polished, structured notes from your recordings in seconds.
Showing 24 of 24 templates
SOAP Note
The most widely used clinical note format across medicine and allied health. Captures the client's self-report (S), your observations and findings (O), your clinical impression (A), and the next steps (P). Suits problem-focused encounters, follow-ups, and any setting where standardised, transferable documentation matters.
DAP Note
Streamlined three-part format favoured in mental health, counselling, and psychotherapy. The Data section combines what the client reported with what you observed; Assessment captures clinical impressions and progress against goals; Plan sets next steps and homework. Faster than SOAP without losing clinical reasoning.
Structured Session Note (BIRP/GIRP/PIRP)
Unified structured session note covering BIRP (Behaviour), GIRP (Goals), and PIRP (Problem) formats. The AI selects the appropriate framing based on your documentation preference.
Process Note
Detailed narrative account of the therapeutic process, including therapist reflections and clinical observations.
Session Note
General-purpose session documentation suitable for a wide range of clinical and allied health encounters, including therapy sessions and treatment sessions.
Initial Assessment
Comprehensive intake assessment covering presenting concerns, history, risk, and treatment goals.
Case Note
Brief, narrative-style note for routine case management, contact records, and inter-agency coordination. Lighter than a full session note — captures who you spoke with, what was discussed, and any actions or follow-up. Useful for community services, social work, and case-managed care.
Consultation Note
Documentation for specialist consultations, second opinions, and inter-professional referrals.
Psychiatric Admission Note
Comprehensive admission note for inpatient psychiatry, mental health units, and acute crisis services. Covers presenting illness, psychiatric and medical history, MSE, risk assessment, formulation, provisional diagnosis, and an initial management plan. Built for the structure ward teams and registrars expect on first contact.
Telehealth Consultation
Documentation format adapted for telehealth and phone consultations. Captures the technology used, identity verification, environment safety, consent for remote care, and any limitations of the modality — alongside standard clinical content. Aligned with AHPRA and Medicare telehealth requirements.
Welfare Concern Record
Documentation for welfare concerns, safeguarding observations, and duty of care reporting.
Psychosocial Assessment
Comprehensive assessment of psychosocial factors including living situation, supports, and barriers.
Group Session Note
Documentation for group therapy and group program sessions with participant-level observations.
Crisis Intervention Record
Detailed record of an acute crisis contact — what triggered the presentation, the de-escalation approach used, risk assessed at the time, and the safety plan put in place. Captures the critical decisions and rationale required for medico-legal review and continuity of care after the event.
Comp. Suicide Risk Assessment
Detailed suicide risk formulation covering ideation, intent, plan, and protective factors.
Palliative Care Consultation
Holistic care note for palliative patients addressing physical, emotional, and spiritual needs.
AOD Comprehensive Assessment
Alcohol and Other Drugs assessment covering substance use history, dependence, and impacts.
Pain Management Assessment
Biopsychosocial pain assessment covering pain history, character and intensity, functional interference, mood and sleep impact, treatment history, and coping strategies. Suitable for chronic pain, persistent musculoskeletal conditions, and pain-management referrals — informs an integrated treatment plan.
Neuroaffirming Session Note
Session documentation for neurodiversity-affirming therapy, capturing sensory state, energy levels, masking load, and progress framed as self-understanding and environmental fit.
Child Therapy Session Note (Brief)
Brief session note for child therapy including play-based and developmental observations, suitable for shorter sessions.
Child Therapy Session Note (Comprehensive)
Comprehensive child therapy note with detailed developmental, behavioural, and family observations for complex cases.
Psychiatric Medication Review
Structured note for psychiatric medication reviews covering current medications, side effects, efficacy, and changes.
Mental Status Examination (MSE)
Standalone Mental Status Examination covering appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition, and insight/judgement. Use as a dedicated MSE record (e.g. on admission) or as an evidence anchor inside a broader assessment. Written in formal psychiatric register.
PROC Note
Five-part psychotherapy progress note format that is structured around an explicit, stated session objective and goal-attainment review. Captures the client's Presentation, a Review of the inter-session period, the agreed session Objective, the therapeutic Content (including formulation, intervention response, and risk), and the forward Plan. Particularly suited to ongoing psychological therapy, supervision-rich practice, and registrar/trainee settings where session-by-session reasoning needs to be visible in the record.
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168 templates across 8 categories. Pick the one that matches your workflow.
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