New patient visit note template

The first visit sets up every later one. If background history is incomplete here, it is usually incomplete for years. This page gives a new patient template for clinic use, a filled invented example of someone transferring their care, the usual omissions, and how the ClearPass New patient structure builds the note.

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Two jobs in one note

A new patient note has to deal with today's reason for attending and also capture the baseline you and colleagues will rely on later. Keep them visibly separate. Put today's problem and its plan at the top, where it will be read first. Put the background (past history, medicines, allergies, family and social history, screening and immunisation status) in its own block that the next clinician can scan.

If the patient brings letters or results from a previous clinic, say which documents you reviewed and what was not available. That is part of the baseline too.

Blank new patient template

Template

NEW PATIENT VISIT
Reason for attending today:
History of today's problem:

BACKGROUND
Past medical history (with year or duration):
Past surgical history:
Current medicines (dose, frequency, who prescribes):
Allergies and reactions:
Family history:
Social history: occupation / living situation / smoking / alcohol / exercise
Preventive care: screening and immunisation status as reported
Documents reviewed:

TODAY
Observations: BP / HR / weight / height / BMI
Examination:

Assessment:
Plan:
  Today's problem:
  Background items to follow up:
Next review:

Copy and adapt. Headings are a common layout, not a regulatory standard.

Filled example: new patient on an anticoagulant

Example

Reason for attending: registering after moving; needs continuing care for atrial fibrillation and repeat prescriptions.
History: atrial fibrillation diagnosed 3 years ago after palpitations; no palpitations in the past year. No bleeding problems. No chest pain or breathlessness.

Past medical history: atrial fibrillation (3 years), hypertension (10 years), osteoarthritis of both knees.
Past surgical history: cholecystectomy.
Medicines: apixaban 5 mg twice daily, bisoprolol 2.5 mg daily, ramipril 5 mg daily, paracetamol as needed.
Allergies: codeine - vomiting.
Family history: mother had a stroke in her 70s.
Social: retired teacher, lives alone, non-smoker, 4 units of alcohol a week, walks daily.
Preventive care: reports flu vaccine last autumn; bowel screening up to date.
Documents reviewed: previous clinic summary letter; last blood tests not available.

Observations: BP 136/80, HR 68 irregularly irregular, weight 71 kg, BMI 26.
Exam: heart sounds normal, chest clear, no ankle oedema.

Assessment: 61-year-old with permanent atrial fibrillation, rate controlled, anticoagulated; hypertension near target.
Plan: continue current medicines. Renal function, full blood count and liver tests to confirm apixaban dose remains appropriate. Request summary from previous clinic. Review in 4 weeks with results.

Invented example for illustration. Not a real patient.

What gets missed at first visits

Allergies listed without the reaction, so an intolerance looks like an anaphylaxis risk or the other way round.
Medicines without dose or prescriber, which makes the first repeat prescription a guess.
Documents reviewed not listed, so nobody knows whether the old summary was seen.
Background issues noticed but not given a plan, such as overdue monitoring bloods.
Family history left blank instead of written as not asked or none known.

The ClearPass New patient structure

Pick New patient before you start. It writes the reason for today's visit and the full background history as well: past medical history, medicines, allergies, family and social history. Tap Transcribe, confirm the patient has agreed, and take the history in conversation; the draft arrives when you tap Stop. First visits tend to be long, and Transcribe handles visits of up to two hours.

Old clinic letters and lab printouts can be photographed, and the clinical details are read into the note. Photos are not automatically redacted, so cover names and numbers first. Choose Detailed if you want every clinical fact that was mentioned; Concise keeps the key points. Review the draft before copying it into your EMR, especially medicine doses, which the numbers check marks if they were not said. For a full inpatient-style baseline, see the history and physical template.

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 is a new patient note different from an H&P?

They overlap. An H&P is usually the full admission or comprehensive assessment with a system-by-system review and examination. A new patient clinic note is often more focused on today's problem plus the background.

Should I document screening and immunisations?

Document what the patient reports and mark it as reported until confirmed. It flags gaps for later visits.

Will ClearPass list a family history the patient did not mention?

No. Sections that were not discussed stay empty or say not discussed, so you can see what still needs asking.

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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