How to Create and Customise Clinical Note Templates in 6 Steps?

Creating and customising clinical note templates is a key strategy for streamlining documentation and improving efficiency in healthcare.

In Australia, mental health professionals spend an average of 11 hours weekly on administrative tasks, much of it related to documentation. Custom templates can significantly reduce this time while maintaining accuracy and ensuring consistency in patient records.

With over 1,300 healthcare facilities in Australia, the need for standardised templates is clear. Tailoring templates to your therapy needs allows mental health professionals like you to quickly and accurately document patient information, from assessments to treatment plans. This targeted customisation enhances communication among teams and minimises errors.

Creating and customising clinical note templates isn’t just about saving time—it’s about empowering mental health professionals to focus on what truly matters: patient care.

This blog will guide you through actionable steps to design efficient and compliant templates tailored to your specific practice needs. Whether you’re seeking to enhance productivity, minimise errors, or reduce burnout, this guide equips you with practical strategies to create clinical note templates that support high-quality care and operational efficiency.

Benefits of Clinical Note Templates

Clinical note templates are an essential tool for mental health professionals, offering numerous benefits that improve documentation accuracy and efficiency. Here are two key advantages:

• Ensure Consistency: Standardised formats capture important details uniformly across visits and providers, enhancing record clarity.
• Save Time: Predefined fields reduce repetitive data entry, allowing therapists to focus on patient care.
• Minimise Errors: Templates improve accuracy by ensuring all essential information is documented.
• Improve Team Collaboration: Clear, structured notes enable seamless sharing and interpretation within healthcare teams.
• Boost Efficiency: Streamlined documentation processes reduce administrative burdens and speed up workflows.

Having explored the benefits of clinical note templates, the next step is understanding how to select or create a template that aligns with your specific practice needs. Here's a simple guide to help you get started.

1. Selecting and Creating a Clinical Note Template

You can easily create your own clinical notes template by following the steps below:

Navigate to the Templates Section

Start by accessing the templates section in your clinical documentation system. Platforms like PractaLuma provide user-friendly access to all your clinical needs. This is typically located under settings or tools, which depends on the platform you're using.

Choose to Add a New Template

Select the option to create a new template. You can opt for a standard template, which follows a predefined structure, or a custom template that you can tailor to specific clinical needs. Consider layouts that suit your practices to enhance efficiency and accuracy.

Avoid Outdated Templates

Ensure the templates you select or design align with current therapy needs, standards and guidelines. Outdated templates may lack essential fields or fail to meet modern compliance and usability requirements.

Remember to test the template in a live setting before full implementation to confirm its practicality and ensure it effectively supports your workflow.

2. Designing the Template Layout

Designing a layout may seem daunting, but following a few simple tips can make your life as a mental health professional easier.

Utilise Platform-Specific Tools for Layout Design

Use the tools provided by your clinical documentation platform, like PractaLuma, to create an efficient and functional layout. When used correctly, you can streamline template creation and ensure compatibility with the system.

Incorporate Functional Features

Add features such as graphics, symbols, and dynamic data fields to enhance usability and clarity. These elements can improve information visualisation and ensure accurate data capture.

Customise Appearance

Use customisation options to adjust background colours, borders, and other visual elements. A well-designed template should be visually appealing and professional, enhancing readability and ease of use.

Designing a template with the above considerations will lead to an easy-to-use clinical note-making system. To further improve functionality, you can add Functional Form Fields.

3.Adding Functional Form Fields

Adding Functional Fields helps professionals like you to select a specific field, decreasing the amount of information they need to remember constantly and improving the note-taking process.

• Interactive Elements: Insert interactive elements such as drop-down menus, checkboxes, and radio buttons to streamline data entry and reduce errors.
• Specialised Sections: Design specialised sections, such as SOAP notes, using predefined format options for consistency and ease of use.
• Space for Notes: Include text areas for narrative notes to capture detailed descriptions and observations.

Integrating these functional fields into your documentation workflow simplifies data entry and ensures accuracy and consistency across records. To further enhance efficiency, consider using dynamic data fields and tables for seamless information management and presentation.

4. Utilising Dynamic Data Fields and Tables

Efficient documentation relies on integrating tools that simplify data entry and presentation. Dynamic data fields and tables are key components for achieving this.

• Dynamic Data Fields: These fields automatically populate essential patient information, such as names, birth dates, and therapy record numbers, using standard data tags. They eliminate repetitive manual entry and ensure consistency.
• Tables: Tables are ideal for presenting structured data clearly. For example, session reports, medication schedules, or treatment plans can be displayed in an organised format, improving readability and quick reference.

Dynamic fields and tables not only save time but also enhance the overall accuracy of clinical notes.

5. Locking and Saving Templates

Once a template is created, securing and organising it ensures long-term usability and consistency.

• Lock Templates: Lock templates in user mode to protect their design from accidental edits and unauthorised changes.
• Save Systematically: When saving templates -
• Provide clear, descriptive labels for easy identification.
• Categorise templates by note types, such as progress notes or discharge summaries, to streamline retrieval.

This approach maintains a clean and efficient library of templates ready for use at any time.

6. Applying and Managing Templates

Transitioning from design to practical application is the next step in leveraging templates effectively.

1. Applying Templates: Use templates during clinical documentation to standardise patient records and improve workflow efficiency.
2. Managing Templates:

• Turn templates on or off depending on the current requirements.
• Remove outdated templates to declutter the system.
• Duplicate templates to make modifications without altering the original design.

By following these six standard steps, you can create a clinical note template tailored to your practice needs, ensuring accurate documentation, improved efficiency, and better patient care. A well-designed template not only supports your workflow but also enhances collaboration and communication within your team.

Frequently Asked Questions (FAQs)

1. Why are clinical note templates necessary?

A: Clinical note templates ensure consistency, accuracy, and efficiency in documentation. They save time, reduce errors, and improve communication among healthcare teams, allowing professionals to focus more on patient care.

2. Can I customise templates for specific therapy needs?

A: Yes, most documentation systems allow customisation. You can tailor templates to include specific fields, layouts, and formats, such as SOAP notes or narrative sections, ensuring they meet your clinical and compliance requirements.

3. What features should I include in a clinical note template?

A: A good template should have dynamic data fields for auto-populated patient details, structured sections like tables for organised data, and functional form fields such as drop-downs and checkboxes for streamlined entry.

4. How do I ensure that templates meet compliance standards?

A: To maintain compliance, design templates that align with local healthcare regulations, include essential fields for documentation, and update them regularly to reflect current standards.

5. What should I do if my template needs changes?

A: Most systems allow you to duplicate templates for editing, preserving the original version. Test any modified template in a live setting to ensure it meets your needs before full implementation.

6. Are there tools available to simplify template creation?

A: Yes, tools like PractaLuma automate the process by transcribing session recordings and converting them into customisable templates. This eliminates manual work and ensures accurate, consistent notes.

Conclusion

In summary, well-designed templates are indispensable for clinical documentation. They save time, improve accuracy, and enhance workflow efficiency. By incorporating features like dynamic fields and tables, securing templates, and managing them proactively, healthcare providers can focus more on patient care while maintaining high documentation standards.

You can forgo this entire process altogether by using PractaLuma. They streamline your note-taking by recording sessions, transcribing them, and converting them into notes in different formats based on your preferences. Check out PractaLuma today!