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Clinical note templates you can copy and automate

Search by keyword or filter by specialty—general SOAP and H&P formats, psychiatry, therapy, psychology, primary care, and more. Paste into Wavo and let ambient recording or dictation fill the sections from your visit.

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Showing 96 of 96 templates

General

SOAP, H&P, progress, consult, procedure, phone/portal, pre/post-op, wound care, and more.

23 templates

General

SOAP Note

Classic SOAP structure for ambulatory and specialty follow-up documentation.

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General

History and Physical

Comprehensive H&P structure for new-patient evaluations and hospital admissions.

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General

General Progress Note

Ambulatory- and inpatient-friendly progress note for interval updates and problem-based plans.

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General

Consult Note

Structured specialty consult reply with impression and actionable recommendations.

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General

Procedure Note

Concise procedure documentation for bedside and outpatient interventions.

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General

Referral Note

Referral and transfer-of-care structure so the receiving clinician gets a usable handoff.

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General

After-Visit Summary

Patient-facing after-visit summary structure clinicians can generate from the encounter.

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General

Telephone Encounter

Structured phone-visit documentation for advice, triage outcomes, and callback plans.

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General

Patient Portal Message

Inbox documentation structure for portal messages, clinical replies, and escalation.

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General

Medication Refill Note

Refill-request documentation covering review, decision rationale, and monitoring.

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General

Medication Reconciliation

Structured med-rec for admissions, discharges, and ambulatory care transitions.

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General

Preoperative Note

Pre-op evaluation structure for risk assessment, optimization, and clearance.

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General

Postoperative Note

Post-op visit structure for recovery course, complications screen, and next steps.

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General

Wound Care Note

Wound assessment and dressing-plan structure for clinic and longitudinal wound care.

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General

Pain Management Follow-Up

Follow-up structure for chronic or subacute pain regimen review and functional goals.

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General

Annual Physical

Comprehensive annual physical structure for preventive exam and counseling.

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General

Focused Complaint Note

Single-complaint visit skeleton for efficient problem-focused ambulatory notes.

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General

Care Coordination Note

Team-facing coordination note for goals, barriers, and accountable next steps.

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General

Transfer Summary

Interfacility or service-transfer handoff summary with active issues and pending items.

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General

Nurse Triage Note

Protocol-friendly nurse triage documentation with disposition and advice given.

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General

Chronic Pain Visit

Comprehensive chronic pain visit structure for assessment and multimodal planning.

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General

AP Note

A/P-forward note for quick visits when the assessment and plan should lead.

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General

Interval History Note

Brief interval history plus assessment/plan for return and continuity visits.

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Nurse practitioners

NP-framed office, acute, chronic, refill, and telehealth visit templates.

5 templates

Nurse Practitioners

NP Office Visit

Ambulatory NP office visit structure framed for nurse practitioner documentation and MDM.

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Nurse Practitioners

NP Acute Care Visit

Focused NP acute/sick visit note for same-day and episodic ambulatory care.

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Nurse Practitioners

NP Chronic Disease Follow-Up

NP chronic disease follow-up structure for multi-problem ambulatory management.

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Nurse Practitioners

NP Medication Refill Visit

Focused NP visit for medication refills, renewals, and dose titration with monitoring.

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Nurse Practitioners

NP Telehealth Visit

NP telehealth visit structure covering modality, consent, remote assessment, and plan.

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Physician assistants

PA-framed office, urgent care, procedure, inpatient, and pre-op notes.

5 templates

Physician Assistants

PA Office Visit

Ambulatory PA office visit structure for new and established patient encounters.

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Physician Assistants

PA Urgent Care Visit

PA urgent care / walk-in note structure for fast episodic evaluation and disposition.

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Physician Assistants

PA Procedure Note

Documentation structure for PA-performed or PA-assisted procedures and aftercare.

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Physician Assistants

PA Hospital Progress Note

Daily inpatient progress note structure for physician assistants on hospital teams.

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Physician Assistants

PA Preoperative Note

PA pre-op assessment structure for surgical readiness, risks, and peri-op planning.

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Psychiatry

Evaluations, medication follow-ups, MSE, ADHD, consults, and risk documentation.

9 templates

Psychiatry

Psychiatric Intake

Comprehensive intake structure for new psychiatric evaluations, including risk and diagnostic formulation.

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Psychiatry

Psychiatry Follow-Up

Structured follow-up note for ongoing psychiatric care between full intakes.

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Psychiatry

Medication-Management Note

Focused template for psychotropic medication visits and titration follow-ups.

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Psychiatry

Mental Status Examination

Classic MSE structure you can use standalone or embed inside intakes and follow-ups.

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Psychiatry

ADHD Evaluation

Structured ADHD assessment note for adult or adolescent psychiatric evaluation visits.

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Psychiatry

Suicide Risk Assessment

Focused risk documentation structure for suicidal ideation and safety planning.

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Psychiatry

Psychiatric Consult

Consult-style note for answering a referring provider’s question with actionable recommendations.

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Psychiatry

Bipolar Follow-Up

Return-visit structure for bipolar spectrum care with mood episode tracking and stabilizer monitoring.

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Psychiatry

Anxiety Follow-Up

Focused follow-up for GAD, panic, and related anxiety disorders with med and therapy coordination.

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Therapy & counseling

DAP/BIRP/GIRP formats, CBT/DBT sessions, couples therapy, treatment plans, teletherapy, and crisis notes.

14 templates

Mental Health

DAP Note

Simple Data–Assessment–Plan structure for therapy and counseling progress notes.

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Mental Health

BIRP Note

Behavior–Intervention–Response–Plan format commonly used in behavioral health.

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Psychology

Therapy Progress Note

Goal-oriented therapy note for psychologists, counselors, and psychotherapists.

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Mental Health

GIRP Note

Goals–Intervention–Response–Plan format that ties each session directly to treatment goals.

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Mental Health

PIRP Note

Problem–Intervention–Response–Plan structure for problem-focused therapy sessions.

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Mental Health

SIRP Note

Situation–Intervention–Response–Plan format for situational and brief therapy notes.

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Psychotherapy

Therapy Discharge Summary

End-of-episode therapy summary for gains, remaining needs, and aftercare recommendations.

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Psychology

CBT Session Note

Cognitive behavioral therapy session structure for agenda, cognitions, experiments, and homework.

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Psychology

DBT Session Note

Dialectical behavior therapy note for diary cards, targets, skills, and chain analysis.

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Marriage & Family Therapy

Couples Therapy Note

Conjoint couples session structure for patterns, interventions, and relational goals.

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Psychology

Biopsychosocial Assessment

Comprehensive biopsychosocial intake assessment for therapy and psychology evaluations.

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Psychotherapy

Treatment Plan Note

Structured treatment plan with problems, goals, interventions, and review schedule.

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Psychology

Teletherapy Note

Virtual therapy progress note with telehealth logistics, clinical content, and plan.

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Mental Health

Crisis Intervention Note

Crisis encounter structure for precipitant, risk, stabilization, safety plan, and disposition.

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Behavioral health

Psychology intakes, group therapy, and substance-use assessment structures.

3 templates

Addiction Counseling

Substance Use Assessment

Structured assessment for alcohol and drug use history, impact, and level-of-care recommendations.

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Behavioral Health

Group Therapy Note

Per-member group therapy documentation covering topic, participation, response, and plan.

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Psychology

Psychology Intake

First-visit psychology intake structure for assessment, goals, and treatment recommendations.

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Primary care

Wellness, preventive, acute, and chronic-care notes for FM and IM.

5 templates

Family Medicine

Annual Wellness Visit

Preventive wellness structure aligned with Medicare AWV-style documentation needs.

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Internal Medicine

Chronic Care Follow-Up

Multi-problem chronic disease follow-up structure for ambulatory primary care.

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Family Medicine

Acute Sick Visit

Focused episodic visit structure for URI and other acute primary-care complaints.

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Family Medicine

Preventive Visit

Screening, immunization, and counseling structure for routine preventive care visits.

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Internal Medicine

Internal Medicine Progress Note

Adult ambulatory internal medicine progress note for complex outpatient follow-up.

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Emergency & urgent care

ED H&P, progress, discharge, and urgent-care visit structures.

4 templates

Emergency Medicine

Emergency H&P

ED-oriented history and physical structure for acute encounters.

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Emergency Medicine

ED Progress Note

ED reevaluation and progress structure for evolving emergency encounters.

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Emergency Medicine

ED Discharge Summary

Structured ED discharge documentation for diagnoses, instructions, and follow-up.

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Urgent Care

Urgent Care Visit

Episodic urgent care note structure for fast, focused outpatient acute visits.

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Pediatrics

Well-child, sick visits, and pediatric ADHD follow-up documentation.

3 templates

Pediatrics

Pediatric Well-Child Visit

Age-based well-child structure for growth, development, vaccines, and guidance.

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Pediatrics

Pediatric Sick Visit

Focused acute pediatric visit structure for fever, URI, and episodic illness.

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Pediatrics

Pediatric ADHD Follow-Up

Structured ADHD medication and school-function follow-up for pediatric primary care.

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Hospital medicine

Daily inpatient progress notes and discharge summaries.

2 templates

Hospital Medicine

Hospital Progress Note

Daily inpatient progress note structure for hospitalists and inpatient teams.

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Hospital Medicine

Hospital Discharge Summary

Inpatient discharge summary structure for hospitalists and receiving clinicians.

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Cardiology

Consults, follow-ups, and heart-failure clinic notes.

3 templates

Cardiology

Cardiology Follow-Up

Outpatient cardiology return-visit structure for symptom trajectory, meds, and testing interpretation.

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Cardiology

Cardiology Consult

Structured new cardiology consultation note for referred and first-visit evaluations.

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Cardiology

Heart Failure Clinic Visit

Specialty clinic structure for HF visits focused on volume, GDMT titration, and barriers to care.

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Neurology

Neurology consults, follow-ups, and headache evaluations.

3 templates

Neurology

Neurology Consult

Structured new neurology consultation note for localization-focused evaluations.

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Neurology

Neurology Follow-Up

Return-visit structure for ongoing neurologic care between full consultations.

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Neurology

Headache Evaluation

Focused neurology template for new or complex headache and migraine evaluations.

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Rheumatology

Consults, joint exams, inflammatory arthritis, and biologic follow-ups.

5 templates

Rheumatology

Rheumatology Consult

New rheumatology consultation structure for inflammatory and autoimmune evaluations.

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Rheumatology

Rheumatology Follow-Up

Return-visit structure for ongoing rheumatology care between full consultations.

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Rheumatology

Joint Exam Note

Focused musculoskeletal and joint exam visit structure for targeted rheumatology care.

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Rheumatology

Biologic Therapy Follow-Up

Monitoring visit structure for biologics, tsDMARDs, and conventional DMARD safety.

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Rheumatology

Inflammatory Arthritis Visit

Disease-activity focused visit for RA, PsA, and other inflammatory arthropathies.

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Orthopedics

Musculoskeletal consult and follow-up note structures.

2 templates

Orthopedics

Orthopedic Consult

New orthopedic evaluation structure for MSK complaints, injuries, and surgical counseling.

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Orthopedics

Orthopedic Follow-Up

Return-visit structure for post-operative and ongoing orthopedic care.

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OB/GYN

Prenatal visits and gynecologic problem visits.

2 templates

OB/GYN

OB/GYN Prenatal Visit

Structured obstetric prenatal visit note for routine and high-risk pregnancy follow-ups.

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OB/GYN

OB/GYN Problem Visit

Problem-focused gynecology visit structure for acute and chronic GYN concerns.

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Dermatology

Dermatology consult and follow-up documentation.

2 templates

Dermatology

Dermatology Consult

New dermatology evaluation structure for rashes, lesions, and procedural visits.

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Dermatology

Dermatology Follow-Up

Return-visit structure for ongoing dermatologic care and post-procedure checks.

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Gastroenterology

GI consult structures for ambulatory specialty care.

1 template

Gastroenterology

Gastroenterology Consult

Structured gastroenterology consultation note for new GI evaluations and procedure planning.

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Endocrinology

Endocrine follow-up notes for chronic metabolic care.

1 template

Endocrinology

Endocrine Follow-Up

Return-visit structure for diabetes, thyroid, and general endocrine follow-up care.

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Oncology

Oncology follow-up structures for treatment and surveillance visits.

1 template

Oncology

Oncology Follow-Up

Structured oncology return-visit note for treatment, surveillance, and toxicity management.

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Rehab therapies

Physical therapy, occupational therapy, and speech-language pathology notes.

3 templates

Physical Therapy

Physical Therapy Evaluation

Initial physical therapy evaluation structure for MSK and functional rehab assessments.

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Occupational Therapy

Occupational Therapy Note

OT evaluation/progress structure focused on ADLs, fine motor function, and occupational goals.

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Speech-Language Pathology

Speech Therapy Note

Speech-language pathology note structure for communication and swallowing therapy sessions.

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