When you're documenting patient visits, Ambient Scribe uses note templates to organize the information into clear, structured clinical notes. We offer a variety of standard note templates that are thoroughly tested and ready for you to use right away. These templates help streamline your documentation process and ensure consistency across patient records. If you need something more tailored, you can create your own custom note templates using our template editor, giving you the flexibility to document exactly how you want.
In this article, we'll walk you through our different standard templates and share tips on how to make the most of them, helping you optimize your clinical documentation workflow.
SOAP
This template generates a standard SOAP note, where each section—Subjective, Objective, Assessment, Plan—is populated with information discussed during the encounter. Here's an example note generated using this template with the "Paragraph" format:
Subjective
John presents with a sore throat, difficulty swallowing, and a scratchy throat. He reports a low-grade fever on and off and swollen, tender neck glands. He has noticed white spots on his tonsils. He is concerned about the seriousness of his symptoms and seeks medical advice.
Objective
On physical examination, John appears mildly ill but in no acute distress. Examination of the throat reveals erythema and swelling of the tonsils with the presence of white exudates. The neck examination shows tender, palpable cervical lymphadenopathy. Overall, the exam is normal except for the findings of erythematous and swollen tonsils with white exudates and tender cervical lymphadenopathy.
Assessment
John's symptoms and physical examination findings are consistent with streptococcal pharyngitis (strep throat), confirmed by a positive throat swab test.
Plan
The plan for John includes prescribing a 10-day course of antibiotics to clear up the infection. He is advised to rest, stay hydrated, and avoid spreading the infection by covering his mouth when coughing or sneezing. He should take the full course of antibiotics as prescribed to prevent the infection from coming back. Follow-up is recommended if symptoms worsen or do not improve.
SOAP (ROS & PE enhanced)
This template is an enhanced version of a SOAP note, adding a Review of Systems and Physical Exam to the standard structure. This provides a more comprehensive patient record while maintaining the familiar SOAP format.
The enhanced note comes with special voice commands to streamline your documentation:
For a normal exam: Say "normal physical exam", "exam was unremarkable", "no abnormalities noted on exam", or similar statements. This automatically generates a comprehensive exam report with normal findings.
For a mostly normal exam with specific findings: Say "normal exam except for...[findings]", "physical exam normal other than...[findings]", or "exam unremarkable aside from...[findings]". This generates a comprehensive exam report with normal findings, except for the specific conditions you mention.
For a brief, focused note: Simply omit these keywords. The Physical Exam section will then only include the findings that were explicitly discussed, stated, or dictated during the encounter.
Here's an example of a note generated using this template with the "Paragraph" format:
Subjective
John presents with a sore throat, difficulty swallowing, and a scratchy throat. He reports a low-grade fever on and off and swollen, tender neck glands. He has noticed white spots on his tonsils. John is concerned about the seriousness of his symptoms and seeks treatment.
Review of Systems
General: Present - Low-grade fever. Not Present - Chills, Fatigue, Sweats.Skin: Not Present - Itching, Rash.HEENT: Present - Sore throat, Difficulty swallowing, Scratchy throat, White spots on tonsils, Swollen neck glands. Not Present - Ear pain, Headache, Nasal congestion, Sinus pain.Respiratory: Not Present - Cough, Congestion, Dyspnea, Stuffy nose, Wheezing.Cardiovascular: Not Present - Chest pain.Gastrointestinal: Not Present - Abdominal pain, Constipation, Diarrhea, Nausea, Vomiting.Musculoskeletal: Not Present - Myalgia.Neurological: Not Present - Dizziness, Fainting, Focal neurological symptoms.
Objective
John's vital signs are not explicitly mentioned. On physical examination, he appears mildly ill but in no acute distress. Examination of the throat reveals erythema and swelling of the tonsils with the presence of white exudates. The neck examination shows tender, palpable cervical lymphadenopathy. A rapid strep test is positive.
Physical Exam
General
- General Appearance: Mildly ill but in no acute distress
- Orientation: Alert and oriented x3
- Build & Nutrition: Well-nourished
- Posture: Normal
- Hydration: Well-hydrated
- Voice: Normal
Integumentary
- Global Assessment: Skin warm and dry, no rashes or lesions
Head and Neck
- Head Shape: Normocephalic
- Trachea: Midline
Eye
- Eyeball: Normal bilaterally
- Sclera/Conjunctiva: Clear bilaterally
- Pupil: PERRLA
ENMT
- Ears: TMs intact bilaterally, no erythema or effusion
- Nose and Sinuses: No congestion or tenderness
- Throat: Erythema and swelling of the tonsils with white exudates
Chest and Lung Exam
- Respiratory Effort: Normal, no distress
- Auscultation: Clear to auscultation bilaterally
Cardiovascular
- Heart: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops
- Vascular: No jugular venous distension, no carotid bruits, pulses normal and equal bilaterally
Peripheral Vascular
- Upper Extremity: Normal pulses bilaterally
- Lower Extremity: Normal pulses bilaterally
Lymphatic
- Head & Neck: Tender, palpable cervical lymphadenopathy
Abdomen
- Inspection: Normal, no distension
- Auscultation: Normal bowel sounds
- Palpation: Soft, non-tender, no masses
Musculoskeletal
- Range of Motion: Full range of motion in all joints
- Strength: Normal strength throughout
- Gait: Normal gait
Neurological
- Cranial Nerves: Grossly intact
- Motor: Normal tone and strength
- Sensory: Grossly intact
- Reflexes: Normal and symmetric
Assessment
John's symptoms and physical examination findings are consistent with streptococcal pharyngitis (strep throat), confirmed by a positive rapid strep test. The presence of fever, tonsillar erythema and swelling with white exudates, and tender cervical lymphadenopathy support this diagnosis.
Plan
The plan for John includes prescribing a 10-day course of oral antibiotics, likely penicillin or amoxicillin. He is advised to rest, stay hydrated, and use over-the-counter pain relievers such as acetaminophen or ibuprofen for symptom relief. He should avoid spreading the infection by covering his mouth when coughing or sneezing. A follow-up appointment will be scheduled in one week to assess his response to treatment. If symptoms persist or worsen, further evaluation will be considered.
History & Physical
This template generates a History & Physical note, including the following sections:
- Chief Complaint
- History of Present Illness
- Past Medical History
- Medications
- Allergies
- Family History
- Social History
- Review of Systems
- Physical Examination
- Assessment
- Plan
- Lab Results
Each section is populated with information discussed during the encounter.
Like the Enhanced SOAP Note, this template comes with special voice commands to streamline your documentation:
- For a normal exam: Say "normal physical exam", "exam was unremarkable", "no abnormalities noted on exam", or similar statements. This automatically generates a comprehensive exam report with normal findings.
- For a mostly normal exam with specific findings: Say "normal exam except for...[findings]", "physical exam normal other than...[findings]", or "exam unremarkable aside from...[findings]". This generates a comprehensive exam report with normal findings, except for the specific conditions you mention.
- For a brief, focused note: Simply omit these keywords. The Physical Exam section will then only include the findings that were explicitly discussed, stated, or dictated during the encounter.
Note: Sections that have no information are automatically removed from the final report.
Here's an example of a note generated using this template with the "Paragraph" format:
Chief Complaint
Sore throat, difficulty swallowing, and scratchy throat.
History of Present Illness
John presents with a sore throat, difficulty swallowing, and a scratchy throat. He reports having a low-grade fever on and off and swollen, tender neck glands. He also noticed white spots on his tonsils. These symptoms suggest a possible strep throat infection.
Review of Systems
General: Present - Low-grade fever. Not Present - Chills, fatigue, sweats.
Skin: Not Present - Itching, rash.
HEENT: Present - Sore throat, difficulty swallowing, white spots on tonsils, swollen neck glands. Not Present - Ear pain, eye problems, nasal congestion, sinus pain.
Respiratory: Not Present - Cough, congestion, dyspnea, stuffy nose, wheezing.
Cardiovascular: Not Present - Chest pain.
Gastrointestinal: Not Present - Abdominal pain, constipation, diarrhea, nausea, vomiting.
Musculoskeletal: Not Present - Myalgia.
Neurological: Not Present - Dizziness, fainting, focal neurological symptoms.
Physical Exam
General
- General Appearance: Mildly ill but in no acute distress
- Orientation: Alert and oriented x3
- Build & Nutrition: Well-nourished
- Posture: Normal
- Hydration: Well-hydrated
- Voice: Normal
Integumentary
- Global Assessment: Skin warm and dry, no rashes or lesions
Head and Neck
- Head Shape: Normocephalic
- Trachea: Midline
Eye
- Eyeball: Normal bilaterally
- Sclera/Conjunctiva: Clear bilaterally
- Pupil: PERRLA
ENMT
- Ears: TMs intact bilaterally, no erythema or effusion
- Nose and Sinuses: No congestion or tenderness
- Throat: Erythema and swelling of the tonsils with white exudates
Chest and Lung Exam
- Respiratory Effort: Normal, no distress
- Auscultation: Clear to auscultation bilaterally
Cardiovascular
- Heart: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops
- Vascular: No jugular venous distension, no carotid bruits, pulses normal and equal bilaterally
Peripheral Vascular
- Upper Extremity: Normal pulses bilaterally
- Lower Extremity: Normal pulses bilaterally
Lymphatic
- Head & Neck: Tender, palpable cervical lymphadenopathy
Abdomen
- Inspection: Normal, no distension
- Auscultation: Normal bowel sounds
- Palpation: Soft, non-tender, no masses
Musculoskeletal
- Range of Motion: Full range of motion in all joints
- Strength: Normal strength throughout
- Gait: Normal gait
Neurological
- Cranial Nerves: Grossly intact
- Motor: Normal tone and strength
- Sensory: Grossly intact
- Reflexes: Normal and symmetric
Assessment
Streptococcal pharyngitis (strep throat) confirmed by positive rapid strep test. The patient presents with classic symptoms including sore throat, difficulty swallowing, low-grade fever, and white exudates on the tonsils.
Plan
Prescribe a 10-day course of oral antibiotics, such as penicillin or amoxicillin. Advise the patient to rest, stay hydrated, and use over-the-counter pain relievers like acetaminophen or ibuprofen. Instruct the patient to cover their mouth when coughing or sneezing to prevent spreading the infection. Schedule a follow-up appointment in one week to assess the response to treatment.