Clinical Note Template — Patient Encounter Documentation
The Clinical Note Template provides a comprehensive framework for documenting patient encounters across all healthcare settings. This universal template supports physicians, nurse practitioners, and physician assistants in capturing chief complaint, clinical history, examination findings, diagnostic reasoning, and treatment planning. Designed for flexibility, this template adapts to office visits, hospital encounters, urgent care, and telehealth appointments. The format aligns with E/M documentation requirements (99202-99215, 99221-99223) and supports accurate coding while ensuring thorough patient care documentation. Key sections include patient presentation, comprehensive history, physical examination by system, diagnostic assessment, clinical decision-making, and detailed care plan. Ideal for primary care, specialty practices, hospital medicine, and any clinical setting requiring structured medical documentation.
Template
Clinical Note
Date of Service: [Date] Time: [Time] Visit Type: New Patient / Established / Follow-up / Urgent / Telehealth Provider: [Name, Credentials]---
Chief Complaint
[Primary reason for visit]
Duration: [Onset/timeline]
Severity: [Acute/Chronic] [Mild/Moderate/Severe]
---
History of Present Illness
Onset: [When symptoms began] Location: [Where symptoms are located] Duration: [How long symptoms persist] Character: [Nature/quality of symptoms] Severity: [X]/10 Aggravating factors: [What makes it worse] Relieving factors: [What makes it better] Associated symptoms: [Related findings] Pertinent negatives: [Relevant symptoms NOT present]---
Review of Systems
Constitutional: [ ] Fever [ ] Chills [ ] Fatigue [ ] Weight change HEENT: [ ] Headache [ ] Vision changes [ ] Sore throat Cardiovascular: [ ] Chest pain [ ] Palpitations [ ] Edema Respiratory: [ ] Cough [ ] Dyspnea [ ] Wheezing GI: [ ] Nausea [ ] Vomiting [ ] Abdominal pain GU: [ ] Dysuria [ ] Frequency [ ] Hematuria MSK: [ ] Joint pain [ ] Back pain [ ] Weakness Neuro: [ ] Dizziness [ ] Numbness [ ] Headache Psych: [ ] Depression [ ] Anxiety [ ] Sleep disturbanceAll other systems reviewed and negative unless noted above.
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Past Medical/Surgical History
Medical Conditions: [Active diagnoses] Surgical History: [Previous surgeries with dates]---
Medications
[Current medications with doses]
---
Allergies
[Drug allergies with reactions] / NKDA
---
Social/Family History
Tobacco: Current / Former / Never Alcohol: [Pattern of use] Family History: [Relevant conditions]---
Physical Examination
Vital Signs
BP: [X/X] | HR: [X] | RR: [X] | Temp: [X]°F | SpO2: [X]% | Wt: [X]
General
[Alert, oriented, appearance, distress level]
HEENT
[Findings]
Cardiovascular
[Heart sounds, rhythm, peripheral pulses]
Respiratory
[Breath sounds, effort]
Abdomen
[Soft/firm, tenderness, bowel sounds]
Other Systems
[As relevant to complaint]
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Diagnostic Results
[Lab/imaging results if available]
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Assessment
1) [Primary Diagnosis]
[Clinical reasoning]
2) [Secondary diagnosis if applicable]
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Plan
Treatment
- [Medications]
- [Procedures/interventions]
Diagnostic Orders
- [Labs/imaging ordered]
Patient Education
- Diagnosis explained
- Warning signs reviewed
Follow-up
- Return: [Timeframe]
- Sooner if: [Specific concerns]
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Provider: [Name, Credentials]💡 Tip: Click anywhere to edit. Changes are temporary.
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