Structured note
Also called Structured clinical note, Template note
A structured note follows fixed headings, such as history, findings, assessment and plan, so omissions stand out and readers find information fast.
Why it matters in a workup
Fixed headings make a missing allergy line or an absent plan obvious. They also make notes easier to compare over time.
Templates help when they prompt the right content. They hurt when they fill a note with defaults nobody checked.
Put it into practice
- Use the same headings for the same document type
- Delete template text you did not verify
- Keep findings and interpretation under separate headings
Frequently asked questions
Do structured notes take longer to write?
Not usually once the structure is familiar. They often save the reader more time than they cost the writer.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- SOAP noteA SOAP note structures a clinical entry as Subjective, Objective, Assessment and Plan, separating what the patient reports from what you found and concluded.
- SBARSBAR is a structure for clinical communication: Situation, Background, Assessment and Recommendation. It is widely used for handovers and escalation.