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.
Which note to write
Pick the format that matches the job. The next reader should know, from the heading alone, whether this was a visit, a phone call, a procedure, or a handoff out of hospital.
| Note type | Use it when | Do not use it when |
|---|---|---|
| SOAP / encounter | A clinic, ED, or virtual visit that needs history, exam, assessment, and plan | You are only documenting a phone result or a daily ward interval |
| Progress (ward) | Inpatient day: what changed since yesterday | You are discharging, or seeing a new outpatient |
| Consult | A specialist opinion requested by another clinician | You are the MRP writing the daily note |
| Procedure | You performed a procedure (I&D, joint injection, IUD, biopsy, suturing) | The visit was counselling only |
| Telephone / inbox | Advice, results, pharmacy clarification, no exam | The patient was in the room and you examined them |
| Discharge summary | Hospital (or ED observe) stay is over; GP and patient need the handoff | The patient is still admitted |
Fictional patients
Worked examples on this page are made-up. College standards, billing schedules, and your EMR templates still govern what you sign. Dedicated pages exist for SOAP, ward progress notes, and discharge summaries if you need the full template.
SOAP and other encounter notes
SOAP (Subjective, Objective, Assessment, Plan) is the default for a Canadian family-medicine or walk-in visit. DAP collapses S and O and is common in mental health follow-up. Narrative letters still need the same four ideas. If the visit is a full encounter with history and exam, write SOAP — or open the SOAP note template page for section rules and clinic examples.
Encounter note (SOAP)
Date / clinician / visit type: S: CC, HPI, pertinent PMHx, meds/allergies, ROS O: vitals, exam, point-of-care results in hand A: numbered working diagnoses P: tests, treatment, counselling, follow-up, safety-net, forms
Consult notes
A consult is an answer to a question, written for the referring clinician. Lead with the question ('Please assess iron-deficiency anemia for GI source'), then focused history and exam, then a clear opinion and a plan you will or will not take over. Do not bury the recommendation under two pages of pasted labs. Copy the referrer. If you assume ongoing care, say so; if you are sending the patient back, say that too.
Consult letter
Referring clinician / question: Source of history: Focused history and exam: Pertinent results reviewed: Opinion: Recommendations (who orders, who follows): I will / will not assume care for this problem: Copy to:
Outpatient GI consult (excerpt)
58-year-old man, Ottawa. Fictional.
Question (Dr. Y. Chen, FP): iron-deficiency anemia, no overt GI bleeding, please advise. Opinion: Likely chronic GI blood loss. No alarm dysphagia. I recommend colonoscopy and gastroscopy; I have booked both rather than sending him back to the queue. No iron infusion today — oral ferrous fumarate 300 mg daily if tolerated, recheck CBC/ferritin with you in 8 weeks. I will write after endoscopy. I am not assuming long-term anemia care. Copy: Dr. Chen.
Procedure notes
If you put a needle, scalpel, or device into the patient, write a procedure note even when the visit also has a SOAP. Consent, indication, timeout/site, technique, findings, specimens, complications, aftercare, and who was present. A one-line 'I&D done' does not show sterility, anesthetic dose, or what you told the patient to watch for.
Procedure note
Procedure / indication / consent (risks discussed, questions answered): Time-out / site / laterality / allergies: Anesthesia / prep / sterility: Technique and findings: Specimens / images: Complications / tolerance: Aftercare, dressings, return precautions, follow-up: Assistants:
In-office incision and drainage
27-year-old, London ON. Fictional.
Procedure: I&D left posterior thigh abscess. Indication: 4 cm fluctuant abscess, 3 days, no fever. Consent: bleeding, recurrence, scar, need for packing change; verbal consent documented. Timeout: left thigh, patient identified. 1% lidocaine with epinephrine 8 mL local. Chlorhexidine. Sterile field. 11-blade incision ~1.5 cm, pus drained, loculations broken with blunt probe. Packed with iodoform, dry dressing. Swab sent for C&S. Tolerated well, no bleeding at rest. Aftercare: packing change 48 h clinic; warm compresses; return if fever, spreading erythema, or hypotension. No empiric antibiotic (no cellulitis, not immunocompromised).
Telephone and inbox notes
Phone, portal, and pharmacy calls are part of the chart. Record who called, capacity to take advice, what was asked, what you reviewed, the advice given, and the safety-net. Do not convert a telephone note into a SOAP with a fake exam. If the story needs an exam, say 'advised in-person today' and document that you said it.
Telephone / inbox note
Date / time / caller / relationship / callback number: Reason: Chart reviewed (meds, last visit, results): Advice / orders / prescriptions: Safety-net / when to come in or go to ED: Follow-up:
Results call
Family practice, Regina. Fictional.
2026-08-26 14:10. Called patient (self), confirmed DOB. Urine culture 24 Aug: E. coli, sensitive to nitrofurantoin (already on day 3 of 5). Symptoms gone. Advised complete course. Recheck only if dysuria returns or fever/flank pain — then ED. No new Rx. Message also in portal.
Progress and discharge
Daily inpatient notes and the hospital-to-GP letter have their own pages. Use a progress note for the ward interval (vitals, overnight events, today's plan). Use a discharge summary when the stay ends: diagnoses, course, medication reconciliation, pending results with an owner, and follow-up. Do not let the last progress note stand in for a discharge letter.
- SOAP encounter template — clinic and ED visits.
- Progress note template — ward daily notes.
- Discharge summary template — hospital to GP, with med rec and pending results.
Match the template to the encounter
Scribeberry has SOAP, consult, procedure, telephone, progress, and discharge templates, or you can build your own headings. Record or dictate, generate, edit, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What are the main types of clinical notes?
Encounter notes (often SOAP), inpatient progress notes, consult letters, procedure notes, telephone or inbox notes, and discharge summaries. Mental health teams may use DAP or BIRP. The right type is the one the next clinician expects for that event.
When should I write a telephone note instead of SOAP?
When there was no in-person or virtual exam: results, prescription clarification, advice, or triage. If you tell the patient to come in, the phone note records that advice; the visit gets its own SOAP.
Do procedure notes replace the visit note?
Usually you need both, or a SOAP with a labelled procedure section. The visit note captures indication and aftercare in the assessment and plan. The procedure section captures consent, technique, dose of anesthetic, and specimens.
Can Scribeberry switch templates by visit type?
Yes. Choose SOAP, consult, procedure, telephone, progress, discharge, or a custom template before you generate. You review the draft before it goes to the EMR.
Templates
