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Note Sections that Include Templates

Updated: 01/15/2022
Views: 4232

Templates are located in various sections throughout the encounter note. The table below outlines the sections in each note type where templates are available.

Review Note Types and Default Sections to learn more about each note type's default sections and entry options.

Note Type Sections with Templates

H&P

(History and Physical)

  • HPI
  • ROS
  • Mental/Functional
  • EXAM
  • Plan
  • Minor Procedures
  • Goals

SOAP

  • Subjective
  • Mental/Functional
  • Objective
  • Plan

Acupuncture Follow Up

  • Subjective
  • Objective
  • TCM Exam
  • Plan
  • Treatment

Acupuncture Initial Visit

  • Subjective
  • Objective
  • TCM Exam
  • Plan
  • Treatment

Acupuncture Reassessment

  • Subjective
  • Objective
  • TCM Exam
  • Plan
  • Treatment

Group

  • DSM-5
  • Plan

Med Spa IV Procedure

  • Procedure
  • Performed By
  • Indication

Med Spa Procedure

  • Procedure
  • Performed By
  • Indication

Nurse Visit

  • HPI

OB Evaluation

  • HPI
  • Past Pregnancy Hx
  • Mental/Functional
  • Exam
  • Gestational Age
  • OB Exam
  • Past Lab Hx
  • Plan

Office Form

  • Form

Physical Therapy Discharge Summary

  • Reason for Referral
  • Subjective
  • Objective
  • Tests and Measures
  • Treatment
  • Plan

Physical Therapy Initial Evaluation

  • Reason for Referral
  • Subjective
  • Objective
  • Tests and Measures
  • Treatment
  • Plan

Physical Therapy Interim

  • Reason for Referral
  • Subjective
  • Objective
  • Tests and Measures
  • Treatment
  • Plan

Physical Therapy Progress

  • Reason for Referral
  • Subjective
  • Objective
  • Tests and Measures
  • Treatment
  • Plan

Procedure

  • Procedure
  • Performed By
  • Indication

Psych Initial Visit

  • HPI
  • PsychHx
  • PsychFHx
  • PsychSHx
  • MSE
  • Tests
  • Psych Impression
  • DSM-5
  • Plan

Psych Progress

  • Psych Symptom/Follow Up
  • Psych Syndromes
  • MSE
  • Psych Impression
  • DSM-5
  • Psych Intervention
  • Plan

Speech and Language Initial Evaluation

  • History
  • Speech Development
  • Receptive/Expressive Language
  • Pragmatics
  • Oral Mechanism Exam
  • Articulation
  • Fluency
  • Voice
  • Plan

Speech and Language Progress Report

  • Subjective
  • Receptive/Expressive Language
  • Pragmatics
  • Oral Mechanism Exam
  • Articulation
  • Fluency
  • Voice
  • Plan

Speech and Language Treatment Note

  • Subjective
  • Objective (Speech/Language)
  • Plan

Telehealth H&P

  • HPI
  • ROS
  • Mental/Functional
  • EXAM
  • Plan

Telehealth SOAP

  • Subjective
  • Mental/Functional
  • Vitals
  • Objective
  • Plan

Therapist Initial Visit

  • HPI
  • PsychHx
  • PsychFHx
  • PsychSHx
  • MSE
  • Tests
  • Psych Impression
  • DSM-5
  • Plan

Therapist Progress

  • Psych Symptom/Follow Up
  • Psych Syndromes
  • MSE
  • Psych Impression
  • DSM-5
  • Psych Intervention
  • Plan

Urgent Care

  • HPI
  • ROS
  • Exam
  • Diagnostic Studies
  • Medical Decision Making
  • Plan
  • Minor Procedures
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