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Note Types and Default Sections

Updated: 09/24/2020
Views: 2312

Kareo provides several types of notes. Each note type contains default sections with various entry options to make documenting easy. The table below outlines the default sections for each note type and the type of entry options under each section. You can always add sections to, or remove sections from, the default list.

Note Type Default Section Headers and Entry Options

H&P

(History and Physical)

CC: Text Shortcut and free-form text
HPI: Text Shortcut, Template, and free-form text
PMHx: Select past medical history (e.g., Blindness, Angina, Gout, etc.)
PSHx: Select past surgical history (e.g., Appendectomy, LASIK, etc.)
FHx: Select family history (e.g., Diabetes, Hypertension, etc.)
Soc Hx: Select social history (e.g., Former smoker, Wear seatbelts, etc.)
Ob Preg Hx: Select OB and pregnancy history (e.g., History of HRT Use, Total Pregnancy, etc.)
Hospitalizations: Add and manage hospitalizations or procedures
Implantable Devices: Add and manage implantable devices
ROS: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Mental/Functional: Screening Tools, Text Shortcut, Template, and free-form text
Vitals: Add and manage vitals
EXAM: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Minor Procedures: Text Shortcut, Template, and free-form text
Goals: Text Shortcut, Template, and free-form text
Health Concerns: Text Shortcut and free-form text

SOAP

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Mental/Functional: Screening Tools, Text Shortcut, Template, and free-form text
Vitals: Add and manage vitals
Objective: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Acupuncture Follow Up

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Objective: Text Shortcut, Template, and free-form text
TCM Exam: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Treatment: Text Shortcut, Template, and free-form text

Acupuncture Initial Visit

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Objective: Text Shortcut, Template, and free-form text
TCM Exam: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Treatment: Text Shortcut, Template, and free-form text

Acupuncture Reassessment

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Objective: Text Shortcut, Template, and free-form text
TCM Exam: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Treatment: Text Shortcut, Template, and free-form text

Amendment

Source of Request: Text Shortcut and free-form text
Request Details: Text Shortcut and free-form text
Decision: Manage decision, Text Shortcut, and free-form text

Group

Group Session Content: Text Shortcut and free-form text
Session Details: Text Shortcut and free-form text
Individual Behavior during Session: Text Shortcut and free-form text
DSM-5: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Med Spa IV Procedure

Procedure: Text Shortcut, Template, and free-form text
Performed By: Text Shortcut, Template, and free-form text
Indication: Text Shortcut, Template, and free-form text
Comments: Free-form text

Med Spa Procedure

Procedure: Text Shortcut, Template, and free-form text
Performed By: Text Shortcut, Template, and free-form text
Indication: Text Shortcut, Template, and free-form text
Comments: Free-form text

Memo to Record

Memo: Free-form text

Nurse Visit

HPI: Text Shortcut, Template, and free-form text
PMHx: Select past medical history (e.g., Blindness, Angina, Gout, etc.)
PSHx: Select past surgical history (e.g., Appendectomy, LASIK, etc.)
FHx: Select family history (e.g., Diabetes, Hypertension, etc.)
Soc Hx: Select social history (e.g., Former smoker, Wear seatbelts, etc.)
Ob Preg Hx: Select OB and pregnancy history (e.g., History of HRT Use, Total Pregnancy, etc.)
Hospitalizations: Add and manage hospitalizations or procedures
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Vitals: Add and manage vitals

OB Evaluation

CC: Text Shortcut and free-form text
HPI: Text Shortcut, Template, and free-form text
PMHx: Select past medical history (e.g., Blindness, Angina, Gout, etc.)
PSHx: Select past surgical history (e.g., Appendectomy, LASIK, etc.)
FHx: Select family history (e.g., Diabetes, Hypertension, etc.)
Soc Hx: Select social history (e.g., Former smoker, Wear seatbelts, etc.)
Ob Preg Hx: Select OB and pregnancy history (e.g., History of HRT Use, Total Pregnancy, etc.)
Past Pregnancy Hx: Text Shortcut, Template, and free-form text
Hospitalizations: Add and manage hospitalizations or procedures
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Mental/Functional: Screening Tools, Text Shortcut, Template, and free-form text
Vitals: Add and manage vitals
Exam: Text Shortcut, Template, and free-form text
Gestational Age: Text Shortcut, Template, and free-form text
OB Exam: Text Shortcut, Template, and free-form text
Past Lab Hx: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Office Form

Form: Text Shortcut, Template, and free-form text

Phone

Discussion: Free-form text

Physical Therapy Discharge Summary

Reason for Referral: Text Shortcut, Template, free-form text
Subjective: Text Shortcut, Template, free-form text
Objective: Text Shortcut, Template, free-form text
Tests and Measures: Text Shortcut, Template, free-form text
Treatment: Text Shortcut, Template, free-form text
Assessment: Text Shortcut, Include Problems
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Physical Therapy Initial Evaluation

Reason for Referral: Text Shortcut, Template, free-form text
Subjective: Text Shortcut, Template, free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Vitals: Add and manage vitals
Objective: Text Shortcut, Template, free-form text
Tests and Measures: Text Shortcut, Template, free-form text
Treatment: Text Shortcut, Template, free-form text
Assessment: Text Shortcut, Include Problems
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Physical Therapy Interim

Reason for Referral: Text Shortcut, Template, free-form text
Subjective: Text Shortcut, Template, free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Vitals: Add and manage vitals
Objective: Text Shortcut, Template, free-form text
Tests and Measures: Text Shortcut, Template, free-form text
Treatment: Text Shortcut, Template, free-form text
Assessment: Text Shortcut, Include Problems
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Physical Therapy Progress

Reason for Referral: Text Shortcut, Template, free-form text
Subjective: Text Shortcut, Template, free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Vitals: Add and manage vitals
Objective: Text Shortcut, Template, free-form text
Tests and Measures: Text Shortcut, Template, free-form text
Treatment: Text Shortcut, Template, free-form text
Assessment: Text Shortcut, Include Problems
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Procedure

Procedure: Text Shortcut, Template, and free-form text
Performed By: Text Shortcut, Template, and free-form text
Indication: Text Shortcut, Template, and free-form text
Comments: Free-form text

Psych Initial Visit

CC: Text Shortcut and free-form text
HPI: Text Shortcut, Template, and free-form text
PsychHx: Text Shortcut, Template, and free-form text
PMHx: Select past medical history (e.g., Blindness, Angina, Gout, etc.)
PSHx: Select past surgical history (e.g., Appendectomy, LASIK, etc.)
PsychFHx: Text Shortcut, Template, and free-form text
PsychSHx: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
MSE: Text Shortcut, Template, and free-form text
Tests: Screening Tools, Text Shortcut, Template, and free-form text
Psych Impression: Text Shortcut, Template, and free-form text
DSM-5: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Psych Progress

CC: Text Shortcut and free-form text
Psych Symptom/Follow Up: Text Shortcut, Template, and free-form text
Psych Syndromes: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
MSE: Text Shortcut, Template, and free-form text
Psych Impression: Text Shortcut, Template, and free-form text
DSM-5: Text Shortcut, Template, and free-form text
Psych Intervention: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Speech and Language Initial Evaluation

CC: Text Shortcut and free-form text
History: Text Shortcut, Template, and free-form text
Speech Development: Text Shortcut, Template, and free-form text
Receptive/Expressive Language: Text Shortcut, Template, and free-form text
Pragmatics: Text Shortcut, Template, and free-form text
Oral Mechanism Exam: Text Shortcut, Template, and free-form text
Articulation: Text Shortcut, Template, and free-form text
Fluency: Text Shortcut, Template, and free-form text
Voice: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Goals: Text Shortcut and free-form text

Speech and Language Progress Report

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Current Goals: Text Shortcut and free-form text
Receptive/Expressive Language: Text Shortcut, Template, and free-form text
Pragmatics: Text Shortcut, Template, and free-form text
Oral Mechanism Exam: Text Shortcut, Template, and free-form text
Articulation: Text Shortcut, Template, and free-form text
Fluency: Text Shortcut, Template, and free-form text
Voice: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Goals: Text Shortcut and free-form text

Speech and Language Treatment Note

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Objective (Speech/Language): Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Goals: Text Shortcut and free-form text

Telehealth H&P

CC: Text Shortcut and free-form text
HPI: Text Shortcut, Template, and free-form text
PMHx: Select past medical history (e.g., Blindness, Angina, Gout, etc.)
PSHx: Select past surgical history (e.g., Appendectomy, LASIK, etc.)
FHx: Select family history (e.g., Diabetes, Hypertension, etc.)
Soc Hx: Select social history (e.g., Former smoker, Wear seatbelts, etc.)
Ob Preg Hx: Select OB and pregnancy history (e.g., History of HRT Use, Total Pregnancy, etc.)
Hospitalizations: Add and manage hospitalizations or procedures
Implantable Devices: Add and manage implantable devices
ROS: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Mental/Functional: Screening Tools, Text Shortcut, Template, and free-form text
Vitals: Add and manage vitals
EXAM: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Goals: Text Shortcut and free-form text
Health Concerns: Text Shortcut and free-form text

Telehealth SOAP

CC: Text Shortcut and free-form text
Subjective: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Mental/Functional: Screening Tools, Text Shortcut, Template, and free-form text
Vitals: Add and manage vitals
Objective: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Therapist Initial Visit

CC: Text Shortcut and free-form text
HPI: Text Shortcut, Template, and free-form text
PsychHx: Text Shortcut, Template, and free-form text
PsychFHx: Text Shortcut, Template, and free-form text
PsychSHx: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
MSE:  Text Shortcut, Template, and free-form text
Tests: Screening Tools, Text Shortcut, Template, and free-form text
Psych Impression: Text Shortcut, Template, and free-form text
DSM-5: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Therapist Progress

CC: Text Shortcut and free-form text
Psych Symptom/Follow Up: Text Shortcut, Template, and free-form text
Psych Syndromes: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
MSE: Text Shortcut, Template, and free-form text
Psych Impression: Text Shortcut, Template, and free-form text
DSM-5: Text Shortcut, Template, and free-form text
Psych Intervention: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text

Urgent Care

CC: Text Shortcut and free-form text
HPI: Text Shortcut, Template, and free-form text
PMHx: Select past medical history (e.g., Blindness, Angina, Gout, etc.)
PSHx: Select past surgical history (e.g., Appendectomy, LASIK, etc.)
FHx: Select family history (e.g., Diabetes, Hypertension, etc.)
Soc Hx: Select social history (e.g., Former smoker, Wear seatbelts, etc.)
Hospitalizations: Add and manage hospitalizations or procedures
ROS: Text Shortcut, Template, and free-form text
Medications: Manage Active, Discontinued, or Not Administered medications
Allergies: Manage Active or Inactive allergies
Vitals: Add and manage vitals
Exam: Text Shortcut, Template, and free-form text
Diagnostic Studies: Text Shortcut, Template, and free-form text
Medical Decision Making: Text Shortcut, Template, and free-form text
Assessment: Text Shortcut, Include Problems, and free-form text
Plan: Text Shortcut, Patient Education, Template, Medications, Vaccines, Labs/Studies, and free-form text
Minor Procedures: Text Shortcut, Template, and free-form text
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