Clinical documents
How to write a clinical assessment
A clinical assessment records the history, the findings, your interpretation and the plan, in that order. Write it so a colleague who has never met the patient can see what you were asked, what you found, what you concluded and what happens next. Keep findings and interpretation in separate sections, and give every plan item an owner.
The Workup Desk team. Last reviewed November 3, 2026. General guidance on clinical documentation, not medical advice about any individual patient.
Start with the question you were asked
Open the assessment with the reason for the consultation and who asked. A cardiology clinic letter that starts with the referrer's question is easier to act on than one that starts with the social history.
When the referral does not state a question, write the one you inferred. The referrer can then see whether you answered what they meant.
Use a consistent structure
Most clinical assessments follow the same sections, whether you write them as a clinic letter, an admission history and physical or a SOAP note. The order matters more than the headings you choose.
| Section | What it contains | Common gap |
|---|---|---|
| Reason for assessment | The question asked and by whom | Missing, so the reader guesses the purpose |
| Sources reviewed | Letters, results and reports, with dates | Results quoted without a date |
| History | Presenting complaint, its timeline and the rest of the history | Red flags asked about but not recorded |
| Examination and investigations | What you observed and measured, normal and abnormal | Interpretation mixed into the findings |
| Assessment | Working diagnosis and a ranked differential | A list with no order and no reasoning |
| Plan | Investigations, referrals, medication decisions, safety-netting, follow-up | Items with no owner or time frame |
Write the history as a timeline
Record the presenting complaint in a short phrase, then tell the history of presenting complaint in the order it happened. Onset, duration, character, triggers, relieving factors and associated symptoms belong there.
Record the red flags you asked about, including the negative answers. A line saying no syncope, no rest pain and no breathlessness at rest tells the reader what you excluded.
Carry forward the facts that change risk. Smoking with pack-years, a relevant family history and current medications with doses all belong in the assessment rather than only in the record.
Keep findings apart from interpretation
Write what you observed and measured in the findings section, with units and dates. Blood pressure 148/92 mmHg, ECG sinus rhythm without ST changes and hs-troponin T 6 ng/L are findings.
Put what those findings mean in the assessment section. A reader who disagrees with your interpretation can still rely on your findings when the two are kept apart.
Rank the differential and state your reasoning
Name the working diagnosis first and say how confident you are. Then list the alternatives in order, with the dangerous ones you have not excluded near the top.
Give one line of reasoning for each. The line that explains why you ranked something lower is often the most useful sentence in the letter.
Write a plan someone else can carry out
Write every plan item as an action with an owner and a time frame. Say which tests you have already requested and which the reader should arrange.
Record the safety-netting advice you gave. Which symptoms should bring the patient back, how urgently and to whom are part of the plan.
- Investigations requested, and who follows up each result.
- Referrals made, with the question each one asks.
- Medication decisions, written as decisions with doses.
- Safety-netting advice, in the words you used with the patient.
- Follow-up, with a date or an interval and a named clinician.
Draft from the sources and edit
When you draft with an AI tool, give it the referral, the letters, the results and your own notes, and ask for the assessment in the structure above. Check each statement against the source it came from.
Edit the draft until it says what you concluded. The assessment carries your name and your clinical judgment, whoever typed the first version.
Questions to check in your own work
- 1.Does the first line say what I was asked and by whom?
- 2.Have I listed the sources I reviewed, with their dates?
- 3.Did I record the red flags I asked about, including the negatives?
- 4.Are findings and interpretation in separate sections?
- 5.Is the working diagnosis named, with the alternatives ranked?
- 6.Does every plan item have an owner and a time frame?
Common questions
Is a SOAP note the same as a clinical assessment?
A SOAP note is one way to structure an assessment. Subjective holds the history, objective holds the findings, assessment holds your interpretation and plan holds the actions. The same separation applies to a clinic letter.
How long should an assessment be?
Long enough that a colleague can act without asking you a question. A complex patient needs more history and a longer plan. A focused follow-up can be short if it states what changed.
Should I copy results into the assessment?
Quote the results that bear on the question, with units and dates. Refer to the full report for the rest, so the letter stays readable.
Try it on one patient's documents
Keep each patient's sources in one workspace, ask questions of them, and draft documents you edit and export. Early access is by invitation.