Write a clinical assessment in a fixed structure
Use the same headings for every assessment so gaps stand out. Download the text file, paste it into your notes or letter template, and fill in each section.
Fill in each section
| Section | What to enter | Example |
|---|---|---|
| Reason for assessment | The question you were asked and who asked it. | Primary care referral: please assess exertional chest pain. |
| Sources reviewed | Each letter, result and report you read, with its date. | Referral, October 20, 2026; ECG report and labs, October 14, 2026; oncology follow-up letter, 2009. |
| Presenting complaint | The main problem in a short phrase, with its duration. | Chest tightness on exertion for six weeks. |
| History of presenting complaint | The story in time order, with the red flags you asked about. | Central tightness on stairs and walking uphill, settles with rest in 2 to 3 minutes. No pain at rest, no syncope. |
| Past history, medications and allergies | Relevant diagnoses with dates, current medicines with doses, and allergies with the reaction. | Hypertension since 2017, hypothyroidism since 2001. Hodgkin lymphoma at 24, ABVD and mediastinal radiotherapy. Ramipril 5 mg and levothyroxine 75 micrograms once daily. No known drug allergies. |
| Family and social history | Family history relevant to the complaint, smoking in pack-years, alcohol, occupation and function. | Father MI at 61. Never smoked. |
| Examination and investigations | What you observed and measured, with units and dates. Interpretation goes below. | BP 148/92, HR 78, BMI 29.4. Soft ejection systolic murmur, right upper sternal border. ECG sinus rhythm, no ST changes. hs-troponin T 6 ng/L. LDL 159 mg/dL, HbA1c 6.2%. |
| Assessment | The working diagnosis, your confidence, and a ranked differential with reasoning. | Typical angina, suspected chronic coronary syndrome. Prior mediastinal radiotherapy raises the likelihood. Murmur raises possible radiation-associated valve disease. |
| Plan | Each action with an owner and a time frame, and the safety-netting advice you gave. | CT coronary angiography and echocardiogram. Refer to cardiology. Advised to seek urgent help if pain at rest. |
Copy the template
CLINICAL ASSESSMENT REASON FOR ASSESSMENT Question asked: Referred by: SOURCES REVIEWED Document and date: PRESENTING COMPLAINT Presenting complaint: HISTORY OF PRESENTING COMPLAINT Onset and duration: Site, character and radiation: Triggers and relieving factors: Associated symptoms: Red flags asked about, present or absent: PAST HISTORY, MEDICATIONS AND ALLERGIES Past medical history: Medications and doses: Allergies and reactions: FAMILY AND SOCIAL HISTORY Family history: Smoking, in pack-years: Alcohol: Occupation and function: EXAMINATION AND INVESTIGATIONS Examination: Results, with value, unit and date: ASSESSMENT Working diagnosis: Confidence: Differential, ranked, with for and against: PLAN Investigations requested and who follows up: Referrals and the question asked: Medication decisions: Safety-netting advice given: Follow-up:
Use it in four steps
- 1
Gather the sources first
Collect the referral, earlier letters and results before you start, and note their dates.
- 2
Fill in the history in order
Work down the headings. A blank field shows you what you have not asked.
- 3
Keep findings apart from your view
Write what you measured under findings and what it means under assessment.
- 4
Give every plan item an owner
Say who does what and by when, and record the safety-netting advice.
Frequently asked questions
Can I paste it into my clinic system?
Yes. The file is plain text, so it pastes into most clinical systems, word processors and letter templates without formatting problems.
Is this the same as a SOAP note?
It follows the same separation of history, findings, assessment and plan, with more headings for a full assessment.
Do I need every section every time?
No. Delete sections that do not apply, but keep the order so readers find things where they expect them.