Clinical Note Examples: 6 Notes Every Clinician Writes

The ScribeMD Team · October 26, 2026

You open the chart for your 2:15 and see last month's note: three lines, one of them "doing well". You can't tell what was examined, what was decided, or why. Now you're rebuilding the story from the patient's memory, and your own note from today will be read by someone else in the same way.

Good clinical notes aren't long. They're clear about what happened, what you found, what you think, and what happens next. This guide gives you clinical note examples for the encounters most outpatient clinicians write every week: a new patient visit, a follow-up progress note, a procedure note, a telehealth visit, a therapy session, and a phone call.

All patient details below are invented. The examples show structure and level of detail, not treatment advice.

What every clinical note needs

Whatever the format, a usable note answers the same questions:

Why was the patient seen? The chief complaint or reason for the visit.
What did they tell you? History in enough detail to support your thinking.
What did you find? Only the exam, results, and measurements you actually obtained.
What do you think is going on? A diagnosis or a working differential.
What's the plan? Tests, treatment, education, follow-up, and when the patient should come back sooner.

Most outpatient notes use SOAP (Subjective, Objective, Assessment, Plan) or a close variant. If you want the template itself, see our SOAP note template with examples.

1. New patient visit (history and physical)

A new patient note is the most complete. It sets the baseline everyone else will build on.

Chief complaint: "Establish care; fatigue for 3 months."
HPI: 46-year-old woman reports gradually worsening fatigue over 3 months. Sleeps 7 hours but wakes unrefreshed. Notes cold intolerance, dry skin, and 4 kg weight gain without diet change. Denies chest pain, shortness of breath, low mood, or heavy menstrual bleeding.
Past medical history: Seasonal allergies. No surgeries.
Medications: Over-the-counter antihistamine as needed.
Allergies: No known drug allergies.
Family history: Mother with hypothyroidism. Father with type 2 diabetes.
Social history: Teacher. Never smoker. Drinks alcohol socially, 2 to 3 drinks per week.
Review of systems: Positive for fatigue, cold intolerance, dry skin. Negative otherwise as per HPI.
Exam: BP 122/76, HR 62, BMI 27. Alert, no distress. Thyroid not enlarged, no nodules. Skin dry. Heart regular, lungs clear. No edema.
Assessment: Fatigue with symptoms suggestive of hypothyroidism, given family history. Also consider anemia and sleep-related causes.
Plan: TSH, free T4, CBC, metabolic panel. Review results by portal. Follow up in 2 weeks, sooner if new symptoms.

2. Follow-up progress note

A progress note is shorter. It focuses on what changed since the last visit and whether the plan is working.

Subjective: 58-year-old man here for hypertension follow-up 4 weeks after starting a new medication. Checking BP at home, readings mostly 128 to 136 systolic. Mild ankle swelling in the evenings, no headache, chest pain, or dizziness. Taking medication daily.
Objective: BP 134/82 (repeat 130/80), HR 70. Trace bilateral ankle edema. Heart regular, lungs clear.
Assessment: Hypertension, improved, close to goal. Mild ankle edema, possibly medication-related.
Plan: Discussed edema as a possible side effect and options. Patient prefers to continue current medication for now. Continue home BP log. Basic metabolic panel today. Return in 3 months, or sooner if swelling worsens.

3. Procedure note

Procedure notes follow a predictable checklist. Missing items, especially consent and complications, are the most common gaps.

Procedure: Punch biopsy, left forearm.
Indication: 6 mm irregularly pigmented lesion, changed in size per patient.
Consent: Risks (bleeding, infection, scarring), benefits, and alternatives discussed. Patient verbalized understanding and signed consent.
Time-out: Performed. Patient, site, and procedure confirmed.
Anesthesia: Local anesthetic infiltrated.
Technique: Site prepped in sterile fashion. 4 mm punch biopsy obtained. Closed with one simple interrupted suture.
Specimen: Sent to pathology.
Blood loss: Minimal.
Complications: None.
Post-procedure: Wound care instructions given. Suture removal in 10 to 14 days. Will call with pathology results.

4. Telehealth visit note

A telehealth note looks like any other visit note, plus a few items that payers and regulators commonly expect. Requirements vary by payer and state, so check the rules that apply to you.

Visit type: Synchronous video visit. Patient at home, clinician in office.
Consent: Patient consented to telehealth visit.
Subjective: 34-year-old woman with 2 days of burning on urination and urinary frequency. No fever, flank pain, or vaginal discharge. Not pregnant. No prior UTIs this year.
Objective: Well-appearing on video, speaking comfortably. Exam limited by video format.
Assessment: Symptoms consistent with uncomplicated cystitis.
Plan: Treatment sent to pharmacy. Return precautions reviewed: fever, flank pain, vomiting, or no improvement in 48 hours should prompt an in-person visit.
Time: Total time on the date of the visit documented, if billing by time.

5. Therapy session note

Behavioral health clinicians often use DAP or BIRP instead of SOAP. Here is a short DAP example.

Data: 50-minute individual session with 27-year-old client with generalized anxiety. Client reports two panic episodes this week, both before work meetings. Practiced the breathing exercise from last session on 3 of 7 days. Affect anxious at start, calmer by end. Denies thoughts of self-harm.
Assessment: Anxiety remains elevated around work performance. Partial engagement with between-session practice. Client is motivated and identifies meetings as the main trigger.
Plan: Continue weekly sessions. Begin cognitive restructuring around meeting-related thoughts. Homework: daily breathing practice and a thought log before meetings. Next session in one week.

For more on these formats, see our guide to DAP notes.

6. Phone encounter note

Phone calls are easy to leave undocumented. A short note is enough, as long as it records the advice given.

Caller: Patient's mother, regarding 4-year-old son.
Reason: Fever since last night.
Details: Highest temperature 38.9 at home. Drinking well, urinating normally, playful between fevers. No rash, breathing difficulty, or stiff neck.
Advice: Home care and fluids reviewed. Call back or seek care for trouble breathing, rash, urinating much less than usual, unusual sleepiness, or fever lasting more than 3 days.
Disposition: Appointment offered for tomorrow morning. Mother accepted.

Common mistakes in clinical notes

Copied-forward text that's no longer true. Old exam findings and resolved problems carried into new notes undermine the whole record.
Documenting exams you didn't do. Template defaults should be edited to match the actual encounter.
Assessment without reasoning. A diagnosis on its own doesn't tell the next clinician why you chose it.
Vague plans. "Follow up as needed" with no return precautions leaves the patient and the next reader guessing.
Notes written hours later. Details fade fast, and end-of-day charting is where most errors creep in.

Where an AI scribe fits

The examples above take time to write well, and most clinicians write them after the visit, often after clinic. An AI medical scribe changes when the writing happens. With the patient's consent, ScribeMD listens to the visit and drafts a structured note, often in under 30 seconds, in the format you use: SOAP, DAP, BIRP, or your own template.

The tradeoffs are real. You need the patient's consent, and you still review every draft, correct what it got wrong, and add what it couldn't hear, like exam findings you didn't say out loud. Expect more edits in the first few weeks. The note is yours: you review it and sign it.

See it on a real encounter

ScribeMD is HIPAA compliant and SOC 2 compliant, works in 30+ languages, and integrates with 35+ EHRs. Book a demo to see a draft note built from a live visit.