Notes in your format, not ours.
SOAP, DAP, BIRP and intake histories are built in. Everything else is yours to write — the sections you actually use, in your order, with your own rules about what to include and what to leave out. This page is the full guide: how to build one, what each box does, and how the same system writes your referral letters.
Three steps, about two minutes
You never write a prompt, and you never edit anything that looks like configuration.
Describe it in one sentence
Dashboard → Your templates → New template. Write what you want the way you would say it to a colleague, then press Draft it. That is the whole input.
"A SOAP note for GP consults, with a red flags section and a safety-netting line at the end."
Edit what comes back
You get a real section list — each with a heading, what belongs in it, and when to leave it out. Rename headings, reword rules, delete sections you do not use, add ones that were missed. Or skip the draft entirely and build the sections by hand.
Nothing saves until you press Save. A draft nobody has read is not a template.
Pick it when you start a session
Your templates appear beside SOAP, DAP, BIRP and History on the Start Session screen, and in the upload window. Choose one and that consultation’s note comes out in your structure.
Coding, differentials, drug interaction and allergy checks and the audit pass all still run.
What each box actually does
A section has four boxes. Three of them shape what gets written. The fourth is the one that is never written at all.
Heading
What gets printed at the top of the section.Write: Write it as you say it — "Risk & Safety Plan", "Parent / Carer Report", "Functional Impact".
Why it matters: This is what you and anyone reading the record sees. It is also how the section is addressed everywhere else in the product, so keep each one distinct.
What goes in it
One sentence describing the content, written as an instruction.Write: "Current medication with dose and frequency, and whether the patient reports taking it as prescribed."
Why it matters: Vague headings produce vague sections. A heading alone leaves the system guessing what "Background" is supposed to mean in your practice.
Rule
When to include the section, and when to leave it blank.Write: "Only include if explicitly discussed. Leave blank otherwise — never infer."
Why it matters: The most valuable box, and the one most people skip. It is what stops a section being filled with what is usually true of a diagnosis instead of what was actually said.
Fixed text
Text reproduced exactly, word for word, every single time.Write: A practice address, a standard consent line, a medico-legal footer, a billing disclaimer.
Why it matters: This one is not written by the AI at all — it is stamped into the note afterwards in code. Reproducing a string unchanged is the one thing a language model should never be trusted with, and these are exactly the strings that must not change.
A worked example
Four sections from a GP consult template, exactly as they are entered.
- What goes in it
- Why the patient came today, in their own words where possible.
- Rule
- Always include.
- What goes in it
- Any symptom or finding raised today that warrants urgent assessment.
- Rule
- Only include if a red flag was actually raised. Leave blank otherwise — never list what was ruled out.
- What goes in it
- What the patient was told to watch for and when to seek help.
- Rule
- Only include if safety netting was discussed.
- Fixed text
- Riverside Medical Centre · 12 Mill Lane · 0161 000 0000
Section 2 stays empty on a visit where no red flag came up — that is what its rule is for. Section 4 prints identically every time, because it is stamped in rather than written.
Free starter templates
Four complete, ready-to-copy templates — full sections, headings, and rules included. Copy one into your own "New template" form as a starting point, or use it as a plain documentation structure with any other system entirely. Free either way.
GP / Primary Care SOAP+
A standard SOAP note with red flags and safety-netting made explicit, rather than buried in Plan.
1. Subjective
What goes in it: The patient's own account of why they came in today, in their words where possible.
Rule: Always include.
2. Objective
What goes in it: Vitals, examination findings and any results reviewed during the visit.
Rule: Always include. Leave a finding out entirely if it was not actually examined — never assume normal.
3. Assessment
What goes in it: The clinician's working diagnosis or differential, in plain clinical language.
Rule: Always include.
4. Plan
What goes in it: Investigations ordered, treatment started or changed, and referrals made.
Rule: Always include.
5. Red Flags
What goes in it: Any symptom or finding raised today that specifically warrants urgent assessment.
Rule: Only include if a red flag was actually raised or actively ruled out by name. Leave blank otherwise.
6. Safety Netting
What goes in it: What the patient was told to watch for, and when to seek further care.
Rule: Only include if safety netting was actually discussed with the patient.
Psychiatric Intake
A first-visit structure that separates history from exam from formulation, instead of one long narrative.
1. Presenting Complaint
What goes in it: Why the patient sought care now, including duration and what changed recently.
Rule: Always include.
2. History of Present Illness
What goes in it: The course of the current episode — onset, triggers, prior episodes if related.
Rule: Always include.
3. Psychiatric & Medical History
What goes in it: Prior diagnoses, hospitalisations, medication trials, and relevant medical conditions.
Rule: Include whatever the patient reports; note explicitly if a history area was not covered rather than leaving it silently blank.
4. Mental State Examination
What goes in it: Appearance, mood, affect, thought form and content, perception, cognition, insight and judgement.
Rule: Always include.
5. Risk Assessment
What goes in it: Suicidality, self-harm, harm to others, and any protective factors identified.
Rule: Always include, even to explicitly document the absence of risk.
6. Formulation
What goes in it: A brief biopsychosocial formulation tying the history and exam together.
Rule: Always include.
7. Plan
What goes in it: Diagnosis under consideration, treatment plan, and follow-up interval.
Rule: Always include.
Therapy / Counselling Follow-up
A shorter structure for an established patient's regular session, not a full reassessment every time.
1. Session Focus
What goes in it: The main topic or goal the patient brought to today's session.
Rule: Always include.
2. Progress Since Last Session
What goes in it: What changed, improved, or worsened since the previous visit, including homework or between-session tasks.
Rule: Only include if there was a previous session to compare against.
3. Interventions Used
What goes in it: The specific technique or approach used today (e.g. cognitive restructuring, exposure, values work).
Rule: Always include.
4. Risk Check
What goes in it: Any change in risk since last contact.
Rule: Only include if risk was specifically discussed or has changed; otherwise a brief "no change noted" is sufficient.
5. Plan for Next Session
What goes in it: What will be covered or attempted before the next appointment.
Rule: Always include.
Specialist Referral Letter
Written from an approved note, addressed to a named specialist rather than a generic recipient.
1. Reason for Referral
What goes in it: The specific question being asked of the specialist, in one or two sentences.
Rule: Always include.
2. Relevant History
What goes in it: Only the history relevant to the referral question — not the full chart.
Rule: Always include.
3. Current Medications
What goes in it: Active medications relevant to the referral, with dose.
Rule: Only include if relevant to the referral question.
4. Investigations to Date
What goes in it: Results already available, so the specialist doesn't repeat them unnecessarily.
Rule: Only include if investigations were actually done.
5. Closing
Fixed text: Please do not hesitate to contact me if further information would be helpful. Thank you for seeing this patient.
Notes and documents are different things
You choose which one a template is when you create it. It decides where the template shows up and when it runs.
Note
Goes into the patient’s record.
Where: Appears as a note format on the Start Session screen and in the upload window.
When: Generated automatically at the end of every consultation you pick it for.
Document
Written from a finished note, for someone outside the practice.
Where: The "Letters & documents" panel at the end of a session, and on any past session in History.
When: On request — most consultations never need one.
Documents are written from your approved note, never from the raw audio. The note is the version you read and signed off; the transcript is not. Something said in the room and then corrected must not be able to reach a letter that leaves your practice.
What works, and what trips people up
Do
- •Keep it to the sections you genuinely use — most doctors settle on between two and eight.
- •Give every section a rule that says what to do when nothing was discussed.
- •Use Fixed text for anything that must never be reworded.
- •Start from a draft and edit it — it is faster than typing sections from scratch.
Avoid
- •Don’t add a section for patient name, age or gender — that is already handled.
- •Don’t save a referral letter as a "note" — it would replace your consultation note.
- •Don’t leave the rule blank on a section that is often not discussed.
- •Don’t write headings as machine names — "presenting_complaint" is printed exactly like that.
Shared across your practice
Colleagues in the same practice see and can use the same templates. One agreed format, not one per doctor.
Editing never rewrites history
Notes already written with a template keep the structure they were written with. Changing it only affects sessions from that point on.
Up to 25 sections
More than that and a note stops being readable. Most doctors settle on between two and eight.
Custom templates are included on Standard and Premium. See plans
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