Gold Standard
We wrote the Gold Standard examples to be as audit-ready as possible, with fuller clinical detail. Use them to study the structure and reasoning before applying the template to your own client.
Clinical Documentation Templates and Examples
See an example before you write your own.
Get fill-in templates and completed examples for seven types of clinical documentation. Compare the fuller Gold Standard versions with Good Enough examples written for realistic time targets.
$47Branded PDFs · Google Drive delivery · files updated in place
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Two levels of detail
Choose a reference for the detail you need.
Both versions include clinical reasoning and the required document elements. The difference is how much detail we use to explain them.
Good Enough
The Good Enough examples aim to get as close to that standard as possible within a realistic writing timeframe. They use less detail while retaining the clinical reasoning and required elements.
What both levels keep
Check that a shorter note still explains your decisions.
Both versions show what needs to be clear, even when you write with less detail.
What needs to be documented here?
Use the template for the document you're writing, since the required content differs by document type.
Can the medical necessity be understood?
Explain how the diagnosis and functional impairment support the proposed care, including the expected benefit.
Is it consistent with the rest of the chart?
Check the information against earlier findings and the current treatment goals.
How much time will you need?
Use the Good Enough time targets as a starting point, allowing more time when the clinical situation requires it.
Seven document types
Templates for seven document types.
Every document includes a fill-in template and a completed example at both levels.
The Good Enough writing targets
The times below are what we aimed for when writing the Good Enough versions. We're trying to make documentation doable within a working day, while getting as close to the Gold Standard's audit readiness as possible.
These are approximate writing targets. Complex cases may need more time and detail. Use your clinical judgment and applicable requirements; neither version can guarantee an audit outcome.
Diagnostic Assessment
Document the presenting problem and clinical formulation. Explain the diagnosis and recommendations, including medical necessity.
Treatment Plan
Operationalize findings through goals, observable objectives, interventions, and discharge criteria.
SOAP Note
Document the session in S/O/I/A/P order and connect it back to the plan.
Case Consult and Collateral Note
Record the purpose and participants, including relevant content and clinical decisions. Address risk and follow-up.
Contact Note
Account for clinically relevant communication and action that occurs between sessions.
Treatment Summary
Summarize treatment and current status for the intended purpose, including the response to treatment and recommendations.
Discharge Summary
Document the reason for discharge and treatment outcome. Include the course of care and risk findings, with recommendations for aftercare and continuity.
Everything in the folder
Templates and completed clinical examples.
Both versions use the fictional client Marcus T., so you can compare how the same case is documented at different levels of detail.
Fill-in template at both levels
Choose the fuller or more time-conscious structure for the document in front of you.
Completed example at both levels
Read the same document as a completed fictional record before writing your own.
Full Marcus chart twice
Compare intake through discharge as a Gold Standard and Good Enough record.
Google Drive delivery
Branded PDFs are updated in place so corrections and new versions reach the folder.
The full comparison
Compare two versions of the same client's record.
Marcus T. is a fictional teaching client. You can review his complete documentation from intake through discharge in both versions.
The fullest clinical reference
Study the fuller clinical explanations in each completed document.
The realistic working reference
Review a more concise version of the same case, including the reasoning behind the clinical decisions.
Intake 16 to discharge 4
The chart stays clinically consistent at both levels from beginning to end.
A clear choice
Choose the templates alone, or get the teaching behind every section.
The $47 pack is for clinicians who want working documents and completed models. The $97 bundle includes this entire pack plus all four courses.
Write it Right: Templates and Examples
Use a completed example as you write.
Choose the level that suits the clinical situation and adapt it to your own client. Where would a completed example help you most?