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Templates

Clinical templates
with worked examples

Blank structures and fictional Canadian cases for the notes you write every day. Review every generated note before it enters the chart.

Clinical notes

Clinical template

SOAP Note Template with Examples

A SOAP note records one encounter in four blocks: Subjective, Objective, Assessment, and Plan. Use the blank below, then look at three fictional Canadian cases written the way a family physician would chart them after a 15-minute visit.

Clinical template

HPI Template with Examples

The history of present illness (HPI) is the story of this problem, from onset to this room. OLDCARTS and OPQRST are checklists so you do not skip character, radiation, or what they already tried. Use the blank below, then three fictional Canadian cases: chest pain, migraine, and abdominal pain.

Clinical template

Medical Chart Template

A medical chart is the whole record, not one visit. The skeleton below is what a family-practice or clinic chart needs before the first SOAP goes in: who the patient is, what can kill them, what they take, and how you will find the last encounter.

Clinical template

Review of Systems Template

A review of systems (ROS) is a screen for symptoms you have not already covered in the HPI. Write the positives and the negatives that change the differential. A 14-system dump copied into every walk-in note does not make the visit more complete.

Clinical template

Discharge Summary Template with Examples

A discharge summary is the hospital-to-GP handoff. The family physician was not on the ward. They need diagnoses, what changed, the medication list that left with the patient, tests still pending, and who owns the next step. Use the blank below, then two fictional Canadian cases — one medical, one surgical.

Clinical template

Progress Note Template with Examples

A ward progress note answers one question: what is different since yesterday, and what are we doing about it today. It is not the outpatient SOAP page and it is not a discharge summary. Use the blank below for a daily inpatient note, then two fictional Canadian examples — medicine and post-operative.

Clinical template

Clinical Notes Template with Examples

Not every encounter is a SOAP note. Clinic visits, ward days, procedures, phone advice, and consults each need a different record. This page is the map: which format to use, a blank for the common types, and when to open the dedicated SOAP, progress, and discharge pages instead.

Clinical template

Medical History Template with Examples

The medical history is the standing record every SOAP, consult, and prescription depends on. In Canadian family practice it lives in the Cumulative Patient Profile (CPP). Build it once, keep it current, and stop pasting a 20-year narrative into every visit note.

Clinical template

Vital Signs Template

Vitals are measurements with a method, a time, and sometimes a reason they were skipped. A blank box next to BP looks the same as 'not needed' and 'machine failed.' Write the number, the units, the route for temperature, the oxygen device, and — when a value is missing — why.

Clinical template

Medication List Template

A medication list is a best possible medication history (BPMH), not a photocopy of last year's EMR field. Include what the patient swallows, inhales, injects, applies, and sleeps with (CPAP, pumps). Capture dose, route, frequency, indication, and whether they actually take it.

Mental health

Clinical template

Mental State Examination Template with Examples

A mental state examination (MSE) is the psychiatric equivalent of a physical exam: what you observe in this encounter, not the life history. Use the blank below, then three fictional Canadian cases written the way a family physician, emergency psychiatrist, or geriatric psychiatrist would chart them.

Clinical template

Biopsychosocial Assessment Template with Examples

A biopsychosocial assessment puts biology, psychology, and social context on the same page. George Engel argued for that in 1977. In Canadian primary care and community mental health it is how you stop treating a PHQ-9 as if it were a housing history.

Clinical template

Therapy Notes Template with Examples

A therapy progress note records one psychotherapy session: what the client brought, what you did, how they responded, and what happens before next time. It is not a mental status exam. Put MSE findings on that page of the chart if you need them; do not let a laundry list of appearance and thought-form eat the intervention.

Clinical template

DAP Notes Template with Examples

A DAP note has three blocks: Data, Assessment, and Plan. Data is what SOAP splits into Subjective and Objective. Mental-health and counselling teams use DAP because a 50-minute session does not need a fake physical exam heading.

Clinical template

Case Note Template

A case note records one mental-health or social-work contact: what was covered, what you observed, risk, what you did, and the next step. It is not a hospital discharge summary and it is not a clinic SOAP for a sore throat. DAP and session-style notes both work if risk and the plan are impossible to miss.

Letters

Clinical template

Doctor's Note Template with Examples

A doctor's note (sick note) is a short clinical letter confirming that you assessed a patient and that work, school, or duties should change for a defined period. Use the blank below, then three fictional Canadian letters. This page is for legitimate notes after a real assessment. Issuing a false note is professional misconduct.

Clinical template

Medical Referral Letter Template with Examples

A referral letter tells a specialist who the patient is, why they are coming, what you have already done, and what you want the specialist to do. Use the blank below, then three fictional Canadian letters: orthopedics, psychiatry, and cardiology.

Clinical template

Medical Certificate Template

A medical certificate is a formal opinion on fitness, restrictions, or duration of disability, usually for work, school, occupational health, or a named third party. It is longer than a sick note and it is still based on an assessment you actually did. Use the blank below, then three fictional Canadian certificates.

Clinical template

Medical Report Template

A medical report is a letter to someone who was not in the room: a referring clinician, an insurer, an employer, or a school. It has a reader, a question, and an opinion grounded in the chart. It is not a SOAP with 'Dear Sir' glued on top.

Clinical template

Medical Release Form

A medical release is consent to disclose personal health information to someone outside the circle of care — an insurer, a lawyer, an employer, a new clinic the patient names, or a family member who is not a substitute decision-maker. It is not a sick note, not a disability form, and not implied consent to treat.

Clinical template

Medical Clearance Form

Medical clearance is your name on a risk decision: surgery, sport, or work. Honest options are cleared, cleared with restrictions, or not cleared. A stamp that says 'fit' when you have not examined the patient, or when restrictions exist, is the version that shows up in a college complaint.

Nursing

Clinical template

Nursing Notes Template with Examples

A nursing note records what you assessed, what you did, and how the patient responded on this shift or visit. Use the blank below, then three fictional Canadian notes written the way an RN or RPN would chart after a med-surg shift, a mental-health observation, or a home-care wound visit.

Clinical template

Nursing Care Plan Template with Examples

A nursing care plan turns an assessment into named problems, measurable goals, interventions, and an evaluation. Use the blank below, then three fictional Canadian plans: post-operative ileus risk after bowel surgery, acute heart-failure fluid overload, and fall risk on a medical unit.

Clinical template

Head-to-Toe Assessment Template

A head-to-toe assessment is a systematic physical exam from airway and neuro status down to skin and mobility. Use the blank below, then three fictional Canadian nursing assessments: COPD exacerbation on admission, post-op day 1 after laparoscopic cholecystectomy, and a post-fall review on a medical unit.

Clinical template

SBAR Template with Examples

SBAR is a four-line spoken (or written) handoff: Situation, Background, Assessment, Recommendation. Use it when you need another clinician to act — the MRP at 02:00, the receiving floor, or the rapid-response team — not as a substitute for the chart.

Guide

Nursing Documentation

Nursing documentation is the timed record of assessment, intervention, and response. Colleges in every province treat it as a professional standard, not optional paperwork. If the next RN cannot see what you found and what you did, the chart failed even if the shift felt busy.

Guide

AI in nursing

Nurses already document more than they are paid to remember: admissions, flows, telephone advice, clinic visits, care plans, and the sentence that explains why a patient went off the floor. AI in nursing, in 2026, mostly means drafting that documentation from what was said or done — not replacing assessment, not titrating insulin, not 'discharging' anyone. This page is for RNs, RPNs/LPNs, and NPs who are being asked to try a scribe or a vendor chatbot and want the job description to stay honest.

Practice

Guide

Medical Charting

Charting is the act of writing in the health record. In Canadian hospitals nurses say 'chart it.' Physicians more often say 'the note.' Both mean the same legal job: a timed, attributable account of what you knew and what you did.

Clinical template

Medical Billing and Coding Template

Billing codes are only as good as the note. In Canada that usually means a provincial schedule of benefits (OHIP, MSP, RAMQ, AHCIP, and the others) plus diagnostic codes your ministry expects. In the United States it usually means CPT for the service and ICD-10-CM for the diagnosis. This template helps you record what you did so a code can be justified. It does not teach you to bill a higher level than the visit.

Guide

EMR system: what it is and where a scribe sits

An electronic medical record (EMR) is the clinic's chart: problems, meds, allergies, visits, labs, letters, and billing hooks. In Canada you will hear EMR more than EHR for community practice. The product names on the desktop — Accuro, OSCAR, TELUS (including PS Suite in many offices), Jane — are not interchangeable, but they all hold the legal record. An AI scribe does not replace that record. It drafts text that you edit and then put into it.

Guide

AI note-taking tools for clinicians

Clinicians searching for AI note-taking tools are usually trying to finish the chart, not capture a lecture. A student recorder that dumps a transcript into a doc is the wrong object. The right object is a tool that knows SOAP from a consult letter, will sit beside an EMR, and will not put PHI on a consumer account you opened with a personal Gmail. This page is for that job.

Guide

AI healthcare companies — by job, not by ranking

Searches for 'AI healthcare companies' often want a leaderboard of fifty startups. That list would be stale before it rendered, and it would pretend that a radiology model and a billing bot are comparable. They are not. This page groups vendors by the job they claim to do. Scribeberry is named where it belongs: a Canada-built ambient documentation (scribe) company. Other firms are described by category, not by insult.

Guide

Patient confidentiality

Patient confidentiality is the rule that health information stays inside the relationship and the people who need it to provide care — unless the law or the patient says otherwise. In a Canadian clinic that conversation now includes PHIPA or another provincial health-privacy statute, PIPEDA when a commercial organization is in the mix, and sometimes HIPAA because a vendor or a patient is in the United States. This is a working high-level map for clinicians, not a legal opinion.

Guide

Continuity of care

Continuity of care is whether the next person — you next Tuesday, the MRP on the ward, the family physician after discharge, the specialist you referred to — can see what was done and what is still open. It is not a slogan about 'relationships.' It is handoffs, discharge, and referral loops that actually close. When those fail, patients repeat tests, restart drugs that were stopped, and sit on wait-lists nobody owns.

Guide

Coordination of benefits

Coordination of benefits (COB) is the set of rules that decides which insurer pays first when a patient has more than one plan. Clinics collect 'other coverage' so claims go to the right payer in the right order — not so the front desk can gossip about someone's workplace. In Canada this usually sits beside a provincial health card, not instead of it. In the US it sits between commercial plans, Medicare, and Medicaid. The clinical note is not a COB form, but a wrong payer still becomes your billing problem.

Guide

Dental practice management software

A dental practice management system (PMS) is the clinic's operations plus the odontogram: schedule, claims, charting of surfaces and perio, imaging links, and recall. It is not a medical EMR with extra tooth numbers glued on. This page explains how dental clinics actually chart and where an AI scribe can sit. It is not a ranking of vendors and it is not a Gartner-style quadrant.

Assessments

Clinical template

Patient Intake Form with Examples

The intake form is what a new patient fills before the first visit — on paper, a portal, or a tablet. It is not the CPP and it is not a SOAP. Staff check identity and the health card; the clinician confirms allergies and medications in the room.

Clinical template

ADHD Assessment Form Template

This page is a chart template for documenting an ADHD workup. It is not a score sheet you can use to diagnose yourself or a family member. In Canada, ADHD is a clinical diagnosis: history, collateral, functional impairment in more than one setting, and a look at the things that mimic it. Rating scales support the interview. They do not replace it.

Clinical template

ADOS Assessment Template

ADOS-2 (Autism Diagnostic Observation Schedule, Second Edition) is a semi-structured, standardized observation used by trained clinicians as part of an autism diagnostic assessment. This page is not a scored ADOS. Scoring and module selection require credentialed use of the published instrument. What you can document in primary care, pediatrics, and developmental clinics is the referral, the history that belongs beside ADOS, and how you file the report you receive.

Clinical template

Trauma Assessment Template

Trauma documentation follows the survey you actually ran: primary (ABCDE), then secondary (head-to-toe plus AMPLE), then a plan that names imaging, consultants, and disposition. This template is for the chart in an emergency department or trauma bay. It is not a substitute for ATLS, your local trauma protocol, or a course card. Findings here are fictional and kept clinical, not graphic.

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