Patient Notes Templates: A Comprehensive Guide for 2025

Updated on: July 15, 2025

Completing patient notes effectively is essential but time-consuming. Using purpose-built templates saves time, improves consistency, and supports accurate clinical decision-making. This guide highlights essential note formats, sample charts, and how DocScrib enhances documentation with AI.

📌 Why You Need Note Templates

• Boost efficiency: Avoid reinventing the wheel—start with structured formats instead.
• Maintain consistency: Ensure all required data is recorded accurately.
• Reduce cognitive load: Follow a clear format so clinicians can focus on care, not memorizing structure.
• Support compliance: Aid in billing, legal standards, and sharing notes with patients.

🛠️ 9 Essential Patient Note Templates

From intake to discharge, different clinical encounters demand tailored note formats:

1. Patient Intake Form – Baseline history and demographics.
2. SOAP Progress Notes – Standard subjective–objective–assessment–plan format.
3. Discharge Summary – Reviews hospital stay and delivers post-discharge guidance.
4. Follow-up Visit Note – Updates patient progress and modifies treatment.
5. Mental Health Note (BIRP, DAP) – Captures behavioral incidents and interventions.
6. Procedural Note – Documents procedures, medications, and patient response.
7. Telehealth Visit Note – Includes virtual-specific elements like connectivity and environment.
8. Referral or Consultation Note – Details recommendations and external provider summaries.
9. Nursing or Allied Health Note – Captures vital signs, interventions, and patient responses.

📊 Best Note Format by Encounter Type

📈 Template Effectiveness Chart

Efficiency Improvement (%)
    0 ──┬────────────┬────────────┬────────────┐
        │            │            │            │
   50%  ──┼────●──────┼────────────┼────────────┤  Procedural Notes
        │         ●  │            │            │  Intake Notes
  100%  ──┼────────────┼────●──────┼────────────┤  Follow‑up SOAP
        │            │        ●   │            │  Telehealth Notes
  150%  ──┼────────────┼────────────┼────●──────┤  Mental Health Notes
        └─────────────────────────────────────────

• All note types improve clinician time by approximately 50–150% when using templates and AI.

🤝 How DocScrib Elevates Documentation

• Built-in templates across formats—SOAP, BIRP, discharge, and more.
• Voice capture during encounters for streamlined entry.
• Automated organization of notes into EHR-ready formats.
• AI suggestions ensure completeness and highlight missing sections.
• Continuous learning adapts templates based on clinician preferences.

🎯 Takeaways

• A diverse library of templates ensures documentation fits the care context.
• Evidence shows templates reduce time and improve quality.
• DocScrib integrates AI to make template-based note-taking effortless, accurate, and clinician-friendly.