A flexible template adaptable for any clinical setting or specialty.
This universal template provides a consistent structure for clinical documentation across all settings. Adapt it to your specialty — add, remove or rename sections as required by your clinical context.
CLINICAL NOTE ===================================== DATE: ___________ TIME: ___________ CLINICIAN: _____________________________ GRADE: ________________________________ LOCATION: _____________________________ PATIENT: ______________________________ DOB: _____________ NHS No: ____________ [or other identifier] REASON FOR ENTRY: [Ward round / Review / Procedure / Review request] —— SUBJECTIVE —————————————————————— Presenting complaint: [Main issue today] History: [Relevant history — onset, duration, character, associated symptoms, relevant background] —— OBJECTIVE —————————————————————— Vital signs: HR: ___ BP: ___/___ RR: ___ Temp: ___ SpO2: ___ BM: ___ Score: ___ Examination: [Relevant clinical findings] Investigations reviewed: [Results discussed] —— ASSESSMENT —————————————————————— [Clinical impression / diagnosis / differential] —— PLAN ———————————————————————————— 1. 2. 3. Escalation plan: ______________________ Follow-up: ____________________________ —— FOOTER ————————————————————————— SIGNATURE: ____________ DATE: _________ NAME (print): __________________________ GRADE: ________________________________ GMC/NMC No: ___________________________