What a clinical note template covers
"Clinical note" is the umbrella term. A primary care visit note, a psychiatric follow‑up and a therapy session note are all clinical notes, and they share a core: who was seen, when and how, why, what the clinician found, what they concluded, what they did and what happens next. Formats like SOAP only decide the order and the headings.
That's why a general clinical note template is useful even if you already use SOAP. Run a finished note against the elements below and you'll catch the gaps that formats don't force you to fill, such as the visit time or the patient's location on a video call.
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Primary care, urgent care, psychiatry medication visits | | Separates the patient's report from exam findings, which medical readers expect |
Routine outpatient therapy | | Short, and the Assessment section keeps clinical judgment in |
Agencies and payers that want interventions spelled out | | Intervention and response each get a heading |
| | Covers the core elements without forcing a structure |
The elements of a clinical note
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| Patient name and ID, date, start and end time, visit type, in person or telehealth, and for telehealth where the patient was |
| Why the patient is here today, in a sentence |
| What changed since the last visit, in the patient's words where it helps |
| What you observed or measured: exam, mental status, screening scores, vital signs |
| Your clinical judgment: diagnosis with ICD-10-CM code, and whether the patient is better, the same or worse |
| What you did during the visit, named specifically |
| Next visit, orders, referrals, patient tasks, and changes to the treatment plan |
| Name, credentials, date signed |
Clinical note example: telehealth follow-up
Priya is a fictional 41‑year‑old patient seen by video for post‑traumatic stress disorder, unspecified (F43.10), after a car accident in March 2026. This is her sixth session of trauma‑focused therapy. All details are invented.
Visit details: Priya S., ID 2291. October 14, 2026, 10:02 to 10:55 am. Individual psychotherapy, video. Patient at home in Ohio, alone in the room. Clinician in the office.
Reason for visit: Scheduled follow‑up for PTSD symptoms.
Interval history: Drove on the highway for the first time since March, with her sister in the car. "My hands were sweating, but I did it." Nightmares down from most nights to two this week. Still avoids the intersection where the accident happened.
Findings: Alert, well groomed, good eye contact on camera. Mood "tired but okay", affect anxious when describing the drive, brighter afterwards. PCL‑5 today 38, down from 52 at intake. Denies suicidal ideation.
Assessment: PTSD, unspecified (F43.10), improving. Avoidance is narrowing. The intersection remains the main trigger.
Interventions: Reviewed the highway drive as an exposure exercise and rated distress before, during and after. Built a graded plan for the intersection, starting with driving past it on a weekday morning as a passenger.
Plan: Priya to complete step one before the next session on October 21 and log her distress ratings. Repeat PCL‑5 in four weeks. No change to diagnosis or frequency.
Signature: M. Okafor, LCSW, signed October 14, 2026.
Blank clinical note template
Copy this into your EHR or a document and replace the prompts.
Visit details: Patient name and ID. Date. Start and end time. Visit type. In person or telehealth. If telehealth: patient location and who else was present.
Reason for visit: One sentence.
Interval history: Changes since the last visit. Patient's own words where they matter.
Findings: Observations, exam or mental status, scores with the instrument named, vital signs if taken.
Assessment: Diagnosis and ICD‑10‑CM code. Better, same or worse, and why you think so. Risk, if relevant.
Interventions: What you did, by name.
Plan: Next visit date. Orders and referrals. Patient tasks. Treatment plan changes.
Signature: Name, credentials, date signed.
Common clinical note mistakes
- An Assessment that only restates the diagnosis. Say whether the patient is improving and what tells you so, like the PCL-5 drop in the example.
- Missing start and end times. Time-based codes depend on them, and they're easy to forget when the session runs over.
- Copy-forward text. A findings section identical to last week's reads as if nobody looked.
- A plan with no date. "Continue therapy" doesn't tell anyone when the next visit is.
- Signing a draft you haven't read. That applies to notes from scribes and AI tools, as the next section explains.
Scribes, AI drafts and your signature
The Medicare Program Integrity Manual, chapter 3, section 3.3.2.4 addresses this directly. When a scribe documents a visit, CMS doesn't require the scribe to sign the note. The treating clinician's signature is what affirms that the note adequately documents the care, and CMS says the same concurrence is required when AI technology transcribes the record. In practice: read every AI draft before you sign it, and correct anything that didn't happen.
HIPAA, Medicare reviews and psychotherapy notes
A clinical note filed in the record is part of the patient's chart, and the patient can request it. Psychotherapy notes are different: HIPAA defines them in 45 CFR 164.501 as a mental health professional's notes on session content, kept separate from the rest of the record.
Section 3.3.2.6 of the same CMS manual says Medicare review contractors must never ask for psychotherapy notes, and refusing to send them can't by itself get a claim denied. But it also says that putting excluded items such as diagnosis, symptoms, progress and session times in the same document as private session content doesn't make them protected. If your only record of a session is a mixed document, you have to pull out what supports the claim yourself. Keeping the clinical note and any psychotherapy notes in separate places avoids that.
Writing clinical notes with Twofold
Twofold listens to the session, or to a summary you dictate, and drafts the note in SOAP, DAP, BIRP or your own structure. You review, edit and sign it. To set up a structure like the one on this page, see custom templates. Our University guide on writing therapy progress notes covers what to check before signing.
Chart notes template, patient chart template, therapy note template, psychiatric SOAP note template, urgent care note template and HPI template.
Reviewed and updated October 2026.
