Clinical Notes Library

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.

  Structure · 4 sections

  1. Subjective
  2. Objective
  3. Assessment
  4. Plan
  Built for

  • General Practitioner
  • Physiotherapist
  • Nurse Practitioner
  • Dietitian
  • +24 more
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• 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.

  Structure · 3 sections

  1. Data
  2. Assessment
  3. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Counsellor
  • Social Worker
  • +23 more
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• 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.

  Structure · 4 sections

  1. Behaviour / Goals / Problem
  2. Intervention
  3. Response
  4. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Counsellor
  • Social Worker
  • +25 more
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• Process Note

  Detailed narrative account of the therapeutic process, including therapist reflections and clinical observations.

  Structure · 5 sections

  1. Presenting Issues
  2. Session Content
  3. Therapist Observations
  4. Reflections
  5. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Psychotherapist
  • Counsellor
  • +14 more
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• Session Note

  General-purpose session documentation suitable for a wide range of clinical and allied health encounters, including therapy sessions and treatment sessions.

  Structure · 7 sections

  1. Homework Review
  2. Session Summary
  3. Key Themes
  4. Interventions
  5. Client Response
  6. Progress Toward Goals
  7. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Counsellor
  • Social Worker
  • +32 more
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• Initial Assessment

  Comprehensive intake assessment covering presenting concerns, history, risk, and treatment goals.

  Structure · 6 sections

  1. Presenting Concerns
  2. History
  3. Mental State Examination
  4. Risk Assessment
  5. Formulation
  6. Treatment Goals
  Built for

  • Psychologist
  • Clinical Psychologist
  • Psychiatrist
  • Counsellor
  • +29 more
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• 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.

  Structure · 5 sections

  1. Contact Details
  2. Purpose
  3. Discussion
  4. Actions
  5. Follow-Up
  Built for

  • Social Worker
  • Case Manager
  • Youth Worker
  • Community Services Worker
  • +16 more
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• Consultation Note

  Documentation for specialist consultations, second opinions, and inter-professional referrals.

  Structure · 5 sections

  1. Reason for Referral
  2. History
  3. Examination
  4. Impression
  5. Recommendations
  Built for

  • Psychiatrist
  • Paediatrician
  • General Practitioner
  • Neuropsychologist
  • +14 more
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• 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.

  Structure · 7 sections

  1. Presenting Problem
  2. Psychiatric History
  3. Medical History
  4. Mental State Examination
  5. Risk Assessment
  6. Formulation
  7. Management Plan
  Built for

  • Psychiatrist
  • Mental Health Nurse
  • Psychologist
  • Clinical Psychologist
  • +4 more
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• 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.

  Structure · 5 sections

  1. Mode of Delivery
  2. Presenting Issues
  3. Assessment
  4. Plan
  5. Telehealth Suitability
  Built for

  • General Practitioner
  • Psychologist
  • Clinical Psychologist
  • Psychiatrist
  • +21 more
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• Welfare Concern Record

  Documentation for welfare concerns, safeguarding observations, and duty of care reporting.

  Structure · 5 sections

  1. Concern Details
  2. Observations
  3. Actions Taken
  4. Notifications
  5. Follow-Up
  Built for

  • School Counsellor
  • Social Worker
  • Youth Worker
  • Teacher
  • +11 more
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• Psychosocial Assessment

  Comprehensive assessment of psychosocial factors including living situation, supports, and barriers.

  Structure · 7 sections

  1. Demographics
  2. Presenting Issues
  3. Social History
  4. Support Network
  5. Risk Factors
  6. Strengths
  7. Recommendations
  Built for

  • Social Worker
  • Counsellor
  • Community Services Worker
  • Psychologist
  • +10 more
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• Group Session Note

  Documentation for group therapy and group program sessions with participant-level observations.

  Structure · 6 sections

  1. Group Details
  2. Session Topic
  3. Activities
  4. Participant Observations
  5. Facilitator Notes
  6. Next Session
  Built for

  • Psychologist
  • Clinical Psychologist
  • Social Worker
  • Occupational Therapist
  • +14 more
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• 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.

  Structure · 6 sections

  1. Crisis Trigger
  2. Presentation
  3. De-escalation Strategies
  4. Risk Assessment
  5. Outcome
  6. Referrals/Follow-up
  Built for

  • Social Worker
  • Psychologist
  • Clinical Psychologist
  • Mental Health Nurse
  • +12 more
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• Comp. Suicide Risk Assessment

  Detailed suicide risk formulation covering ideation, intent, plan, and protective factors.

  Structure · 7 sections

  1. Current Ideation
  2. Intent & Plan
  3. History of Attempts
  4. Risk Factors
  5. Protective Factors
  6. Risk Level
  7. Safety Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Psychiatrist
  • Mental Health Nurse
  • +12 more
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• Palliative Care Consultation

  Holistic care note for palliative patients addressing physical, emotional, and spiritual needs.

  Structure · 6 sections

  1. Symptom Management
  2. Functional Status
  3. Psychosocial Support
  4. Family Needs
  5. Advance Care Planning
  6. Plan
  Built for

  • Nurse Practitioner
  • General Practitioner
  • Social Worker
  • Counsellor
  • +10 more
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• AOD Comprehensive Assessment

  Alcohol and Other Drugs assessment covering substance use history, dependence, and impacts.

  Structure · 6 sections

  1. Substance Use History
  2. Severity of Dependence
  3. Physical Health
  4. Psychosocial Impact
  5. Readiness for Change
  6. Treatment Goals
  Built for

  • Social Worker
  • Counsellor
  • Psychologist
  • Clinical Psychologist
  • +9 more
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• 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.

  Structure · 6 sections

  1. Pain History
  2. Intensity & Quality
  3. Aggravating/Relieving
  4. Functional Interference
  5. Psychological Impact
  6. Management Plan
  Built for

  • Physiotherapist
  • Psychologist
  • Clinical Psychologist
  • Nurse Practitioner
  • +9 more
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• 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.

  Structure · 6 sections

  1. Check-In & Energy Level
  2. Session Focus
  3. Strengths Observed
  4. Strategies Explored
  5. Accommodations
  6. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Occupational Therapist
  • Speech Pathologist
  • +14 more
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• Child Therapy Session Note (Brief)

  Brief session note for child therapy including play-based and developmental observations, suitable for shorter sessions.

  Structure · 5 sections

  1. Session Details
  2. Presentation
  3. Session Content
  4. Parent/Carer Feedback
  5. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Counsellor
  • Social Worker
  • +13 more
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• Child Therapy Session Note (Comprehensive)

  Comprehensive child therapy note with detailed developmental, behavioural, and family observations for complex cases.

  Structure · 8 sections

  1. Session Details
  2. Current Presentation
  3. Developmental Observations
  4. Session Content
  5. Family/System Factors
  6. Risk Assessment
  7. Treatment Progress
  8. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Counsellor
  • Social Worker
  • +14 more
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• Psychiatric Medication Review

  Structured note for psychiatric medication reviews covering current medications, side effects, efficacy, and changes.

  Structure · 7 sections

  1. Session Details
  2. Current Medications
  3. Medication Efficacy
  4. Side Effects
  5. Mental State Examination
  6. Risk
  7. Plan
  Built for

  • Psychiatrist
  • General Practitioner
  • Nurse Practitioner
  • Mental Health Nurse
  • +5 more
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• 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.

  Structure · 11 sections

  1. Examination Details
  2. Appearance
  3. Behaviour
  4. Speech
  5. Mood and Affect
  6. Thought
  7. Perception
  8. Cognition
  9. Insight and Judgement
  10. Risk
  11. Summary
  Built for

  • Psychiatrist
  • Psychologist
  • Clinical Psychologist
  • Mental Health Nurse
  • +10 more
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• 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.

  Structure · 5 sections

  1. Presentation
  2. Review
  3. Objective
  4. Content
  5. Plan
  Built for

  • Psychologist
  • Clinical Psychologist
  • Counsellor
  • Social Worker
  • +13 more
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