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Note Sections that Include Templates

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

Note Type Sections with Templates

H&P (History and Physical)    

HPI

ROS

Cognitive/Functional

EXAM

SOAP

Subjective

Cognitive/Functional

Objective

Plan

Nurse Visit     HPI

Procedure

Performed By

Procedure

Indication

Office Form Form

Psych Initial Visit    

HPI

PsychHx

PsychSHx

MSE

Tests

Psych Impression

DSM-5

Plan

Psych Progress    

Psych Symptom/Follow Up

Psych Syndromes

MSE

Psych Impression

DSM-5

Psych Intervention

Plan

Physical Therapy Initial Evaluation

Physical Therapy Interim

Physical Therapy Progress

Physical Therapy Discharge Summary

Reason for Referral

Subjective

Objective

Tests and Measures

Treatment

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

ACOG

HPI

Past Pregnancy Hx

Cognitive/Functional

Exam

Gestational Age

OB Exam

Past Lab Hx

Plan

Minor Procedures

Group

DSM-5

Plan

Urgent Care    

HPI

ROS

Diagnostic Studies

Medical Decision Making

Plan

Minor Procedures

 

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