Title Page

  • Created on

  • Prepared by

  • Location



  • Patient Name

  • Age

  • Location

  • Briefly describe the current situation or problem.


  • Provide relevant background information about the patient.

  • Primary Problem

  • Relevant Medical History

  • Current Medications

  • Allergies

  • Relevant Interventions or Procedures Done Recently


  • Present your assessment or evaluation of the patient's current condition.

  • Vital Signs

  • Symptoms

  • Relevant Test Results

  • Other Pertinent Clinical Information

  • Interpretation of Current Clinical Status


  • Suggest specific actions or interventions to be taken.

  • Recommendations for Further Diagnostic Tests/Advance Plan of Care

  • Medication Changes or Adjustments

  • Interventions Needed


  • Other Notes

  • Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.