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 GELYPTIC MD draft the same structure from the consultation itself.
10 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.
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.
A musculoskeletal intake structure built around mechanism of injury, objective range of motion, named special tests and a staged conservative-to-operative plan.
A mental health progress note structured around the mental state examination and an explicit, dated risk assessment — the two elements reviewers look for first.
A routine antenatal review structured around gestational age, maternal observations, fetal assessment and the screening schedule for that visit.
A remote-consultation note that records the elements payers and regulators require: consent, modality, both parties' locations, and what could not be examined.
A time-critical ED structure: triage category, focused history and examination, risk score, investigations, reassessment and an explicit disposition decision.
A problem-oriented review note for long-term conditions, built around control markers, adherence, complication screening and an explicit titration decision.
A febrile-illness note built for endemic practice. It forces an explicit differential, records the diagnostic modality and its result in full, keeps weight-banded regimens and day-of-therapy intact, and prompts notification when the working diagnosis is reportable.
One structure for maternal and community health contacts: the clinical record a colleague needs, plus the indicator lines a register, monthly summary or program report needs, captured in the same conversation.
Related
Stop retyping the same structure every visit.
GELYPTIC MD drafts these templates from the consultation. You review and approve.