Custom note templates: build headings that fit your clinic

Standard formats like SOAP work for most visits, but many clinicians have a structure they learned in training or that their service expects. A good custom template puts information where your readers look for it. This guide explains how to design one, gives sample heading sets and shows how to keep it short.

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What a good template does

A template is an agreement about where things go. When every note from a service follows the same order, a colleague can find the medication changes or the follow-up date in seconds. That is the whole point. A template is not a checklist to fill in; it is a map for the reader.

The best templates are short. Each heading should hold something that is usually present and usually needed. Headings that are empty in most notes add scrolling and invite filler text.

Designing your own headings

Collect five of your best notes. Pick notes a colleague praised or found easy to follow. Look at the order you naturally used.
List the headings that appear in all five. Those are your core. Anything that appears in only one is optional and can be added by hand when needed.
Order them by the reader's questions. Most readers want to know why the patient came, what you found, what you think and what happens next, in that order.
Name headings plainly. Use words your service already uses. Avoid abbreviations that only you understand.
Try it for a week, then prune. Remove any heading you left empty most of the time. Merge headings that always hold one line.

Sample heading sets

These are starting points, not standards. Adapt them to your service and any rules your employer sets.

Physiotherapy follow-up: Progress since last session; Pain and function today; Treatment given; Home exercise changes; Goals and next session.
Diabetes review: Symptoms and hypoglycaemia; Readings and results; Medication changes; Feet, eyes and kidneys; Lifestyle; Plan and next review.
Antenatal visit: Wellbeing and symptoms; Observations; Fetal movements and growth; Results; Concerns discussed; Plan.
Mental health review: Current mood and sleep; Risk assessment; Medication and side effects; Supports; Plan and safety plan.
Pre-operative assessment: Planned procedure; Relevant history; Airway and anaesthetic history; Medication instructions; Tests ordered; Fitness decision.

Keep templates lean over time

Templates drift. A heading gets added after an audit, another after a complaint, and within a year the note has fifteen sections. Review your template every few months with the same question: which headings does the next reader actually use? Keep those and let the rest go.

Resist building a separate template for every condition. One structure per visit type, with free text inside it, usually serves better than a library you cannot remember. If you use an AI scribe, a lean template also helps it: fewer headings mean fewer places where it may put a fact under the wrong label.

How ClearPass handles templates

ClearPass offers ready note structures: SOAP, Full headings (nine sections), Follow-up, New patient, Procedure and Problem list. If none fits, choose My own structure: write your headings once and they are reused for every note until you change them. The note from a transcribed visit is then sorted under your headings, in English, ready to paste into your EMR.

For typed cases there are also 300+ guided case templates across 19 groups, from Cardiology to Emergency and Critical Care. If a single note needs a change, such as an extra section or a shorter plan, ask for it in plain words in the Ask box. As always, the note is a draft you review before use.

What ClearPass does not do

It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
It is not a medical device and does not make clinical decisions. It is a documentation aid.
It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

How many headings should a template have?

As few as your readers need. Many good templates have four to seven. If most notes leave a heading empty, remove it.

Should every condition have its own template?

Usually not. One structure per visit type, such as new patient, follow-up or procedure, with free text inside, is easier to maintain and easier to read.

Can I share my template with colleagues?

Share the headings themselves. Agree a set as a team, then each clinician enters the same headings as their own structure, so notes from the service stay consistent.

What does ClearPass cost?

The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.

Try it on your next clinic day

The full product for 7 days, with no card and no automatic charge. Then $78 a month or $858 a year. Pricing details.

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