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Encounter Note Types and Default Sections

Kareo provides several types of encounter 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, free-form text

HPI: Template, Text Shortcut, free-form text

PMHx: Tabbed content

PSHx: Tabbed content

FHx: Tabbed content

Assessment: Text Shortcut, Include Problems, free-form text

Soc Hx: Tabbed content

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Ob Preg Hx: Tabbed content

Hospitalizations: Tabbed content

ROS: Template, Text Shortcut, free-form text

Medications: Tabbed content

Allergies: Tabbed content

Cognitive/Functional: Template, Text Shortcut, free-form text

Vitals: Tabbed content

EXAM: Template, Text Shortcut, free-form text

Minor Procedures:  Template, Text Shortcut, free-form text

SOAP

CC: Text Shortcut, free-form text

Subjective: Template, Text Shortcut, free-form text

Assessment: Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Medications: Tabbed content

Allergies: Tabbed content

Cognitive/Functional: Template, Text Shortcut, free-form text

Vitals: Tabbed content

Objective: Template, Text Shortcut, free-form text

Nurse Visit

HPI:   Template, Text Shortcut, free-form text

PMHx: Tabbed content

PSHx: Tabbed content

FHx: Tabbed content

Soc Hx: Tabbed content

Ob Preg Hx: Tabbed content

Hospitalizations: Tabbed content

Medications: Tabbed content

Allergies: Tabbed content

Vitals: Tabbed content

Procedure

Performed By: Template, text shortcut, free-form text

Procedure: Template, text shortcut, free-form text

Indication: Template, text shortcut, free-form text

Comments: Free-form text

Phone

Discussion: Free-form text

Memo to Record

Memo: Free-form text

Office Form

Form: Template, Text Shortcut, free-form text

Amendment

Source of Request: Text Shortcut, free-form text

Request Details: Text Shortcut, free-form text

Decision: Tabbed content, Text Shortcut, free-form text

Physical Therapy Initial Evaluation

Reason for Referral: Text Shortcut, Template, free-form text

Subjective:  Text Shortcut, Template, free-form text

Medications: Tabbed content

Vitals: Tabbed content

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: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Physical Therapy Interim

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: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Physical Therapy Progress 

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: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, 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: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Psych Initial Visit

CC: Text Shortcut, free-form text

HPI: Template, Text Shortcut, free-form text

PsychHx: Template, Text Shortcut, free-form text

PMHx: Tabbed content

PSHx: Tabbed content

PsychFHx: Template, Text Shortcut, free-form text

PsychSHx: Template, Text Shortcut, free-form text

Medications: Tabbed content

MSE: Template, Text Shortcut, free-form text

Tests: Template, Text Shortcut, free-form text

Psych Impression: Template, Text Shortcut, free-form text

DSM-5: Template, Text Shortcut, free-form text

Assessment:  Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Psych Progress

CC: Text Shortcut, free-form text

Psych Symptom/Follow Up: Template, Text Shortcut, free-form text

Psych Syndromes: Template, Text Shortcut, free-form text

Medications: Tabbed content

MSE: Template, Text Shortcut, free-form text

Psych Impression: Template, Text Shortcut, free-form text

DSM-5: Template, Text Shortcut, free-form text

Psych Intervention: Template, Text Shortcut, free-form text

Assessment: Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Therapist Initial Visit

CC: Text Shortcut, free-form text

HPI:  Template, Text Shortcut, free-form text

PsychHx:  Template, Text Shortcut, free-form text

PsychFHx:  Template, Text Shortcut, free-form text

PsychSHx:  Template, Text Shortcut, free-form text

Medications: Tabbed content

MSE:  Template, Text Shortcut, free-form text

Tests: Template, Text Shortcut, free-form text

Psych Impression:  Template, Text Shortcut, free-form text

DSM-5:  Template, Text Shortcut, free-form text

Assessment: Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Therapist Progress

CC: Text Shortcut, free-form text

Psych Symptom/Follow Up: Template, Text Shortcut, free-form text

Psych Syndromes: Template, Text Shortcut, free-form text

Medications: Tabbed content

MSE: Template, Text Shortcut, free-form text

Psych Impression: Template, Text Shortcut, free-form text

DSM-5: Template, Text Shortcut, free-form text

Psych Intervention: Template, Text Shortcut, free-form text

Assessment: Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

ACOG

CC: Text Shortcut, free-form text

HPI: Template, Text Shortcut, free-form text

PMHxTabbed content

PSHx: Tabbed content

FHx: Tabbed content

Soc Hx: Tabbed content

Ob Preg Hx: Tabbed content

Past Pregnancy Hx: Template, Text Shortcut, free-form text

Hospitalizations: Tabbed content

Medications: Tabbed content

Allergies: Tabbed content

Cognitive/Functional: Template, Text Shortcut, free-form text

Vitals: Tabbed content

Exam: Template, Text Shortcut, free-form text

Gestational Age: Template, Text Shortcut, free-form text

OB Exam: Template, Text Shortcut, free-form text

Past Lab Hx: Template, Text Shortcut, free-form text

Assessment: Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Group

Group Session Content: Text Shortcut, free-form text

Session Details: Text Shortcut, free-form text

Individual Behavior during Session: Text shortcut, free-form text

DSM-5: Template, Text Shortcut, free-form text

Assessment: Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Urgent Care

CC: Text Shortcut, free-form text

HPI: Template, Text Shortcut, free-form text

PMHx: Tabbed content

PSHx: Tabbed content

FHx: Tabbed content

Soc Hx: Tabbed content

Hospitalizations: Tabbed content

ROS:  Template, Text Shortcut, free-form text

Medications: Tabbed content

Allergies: Tabbed content

Vitals: Tabbed content

EXAM: Template, Text Shortcut, free-form text

Diagnostic Studies:  Template, Text Shortcut, free-form text

Medical Decision Making:  Template, Text Shortcut, free-form text

Assessment:  Text Shortcut, Include Problems, free-form text

Plan: Template, Labs/Studies, Text Shortcut, Patient Education, Medications, Vaccines, free-form text

Minor Procedures:  Template, Text Shortcut, free-form text

 

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