Problem list note template

When a patient has several conditions, a single assessment paragraph mixes them together and plans get lost. A problem-oriented note fixes that by numbering the problems and handling each in turn. Here is a blank template, a filled invented example for a patient with four conditions, the usual pitfalls, and the ClearPass Problem list structure.

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How a problem-oriented note works

The note starts with a short summary of the visit and a numbered list of active problems. Each problem then gets its own block: the relevant subjective and objective details for that problem, the assessment, and the plan. The next reader can go straight to problem 3 without reading the rest.

The list itself is the valuable part. Keep it current: move resolved problems to a past list, merge duplicates, and name problems as specifically as you can. Chronic kidney disease stage 3a is more useful than kidney problem.

Blank problem list template

Template

PROBLEM-ORIENTED NOTE
Visit summary:

Active problems:
  1.
  2.
  3.

1. [Problem]
   Update:
   Findings / results:
   Assessment:
   Plan:

2. [Problem]
   Update:
   Findings / results:
   Assessment:
   Plan:

3. [Problem]
   Update:
   Findings / results:
   Assessment:
   Plan:

Resolved or inactive problems:
Medicines reconciled: yes / no
Next review:

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

Filled example: four chronic conditions

Example

Visit summary: 72-year-old for 6-monthly chronic disease review. Feels well overall, knees limiting walking.

Active problems:
1. Type 2 diabetes
2. Hypertension
3. Chronic kidney disease stage 3a
4. Osteoarthritis both knees

1. Type 2 diabetes
   Update: no hypoglycaemia, diet unchanged.
   Results: HbA1c 56 mmol/mol (from 61). Foot check: pulses present, sensation intact.
   Assessment: improving, near individual target.
   Plan: continue metformin 500 mg twice daily (dose limited by eGFR). Retinal screening due - booked.

2. Hypertension
   Update: home readings average 138/82.
   Findings: clinic BP 142/84.
   Assessment: slightly above target.
   Plan: amlodipine increased from 5 mg to 10 mg daily (clinician's decision). Recheck home readings in 4 weeks.

3. CKD stage 3a
   Results: eGFR 52 (stable from 54), urine albumin:creatinine ratio 4.1.
   Assessment: stable.
   Plan: continue ramipril. Avoid regular anti-inflammatories. Repeat renal function and urine ACR in 6 months.

4. Knee osteoarthritis
   Update: pain 6/10 on walking, can manage 10 minutes.
   Assessment: symptomatic, limiting activity.
   Plan: physiotherapy referral, weight and activity advice, paracetamol as needed; topical anti-inflammatory gel acceptable.

Next review: 4 weeks for BP, 6 months for full review.

Invented example for illustration. Not a real patient.

Pitfalls in problem-based notes

Listing symptoms and diagnoses side by side, so the same issue appears twice under different names.
Plans that cross problems without saying so, such as an oral anti-inflammatory for the knees in a patient with kidney disease.
Resolved problems never moved off the active list.
Placing a result under the wrong problem, which hides it from the person reviewing that condition.
A long list with no order. Put the problem that drove today's visit first.

The ClearPass Problem list structure

Choose Problem list. The draft opens with a numbered list of active problems, then takes each one in turn with its own assessment and plan, as in the example. It suits chronic disease reviews, older patients on many medicines, and busy inpatient reviews. ClearPass takes the problems from what was discussed; it does not pull in a list from your EMR, because it does not connect to one. If you want the full existing list in the note, read it out or paste it in at the start.

Numbers such as HbA1c or eGFR that appear in the draft but were not said are marked for review. A photographed lab report can supply the values instead. Use the Ask box for edits in plain words, for example move the knee plan to problem 1 or add retinal screening. The draft is yours to check and correct before it is used. For a single-problem visit, a follow-up note or SOAP note is simpler.

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

When is a problem list better than SOAP?

When there are two or more active problems with separate plans. For a single acute complaint, SOAP is usually shorter and clearer.

Should every problem be reviewed at every visit?

No. List all active problems, but it is fine to write not addressed today under a problem that was not discussed.

Can ClearPass order the problems the way I want?

Ask it in plain words through the Ask box, or edit the draft directly before copying.

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

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