Note Sections that Include Templates

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Updated: 06/30/2023 | Views: 8245

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
Consultation	HPI ROS Mental/Functional EXAM Plan Minor Procedures Goals
Discharge Summary	Discharge procedure HPI Discharge physical findings Hospital course
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

H&P

SOAP

Acupuncture Follow Up

Acupuncture Initial Visit

Acupuncture Reassessment

Consultation

Discharge Summary

Group

Med Spa IV Procedure

Med Spa Procedure

Nurse Visit

OB Evaluation

Office Form

Physical Therapy Discharge Summary

Physical Therapy Initial Evaluation

Physical Therapy Interim

Physical Therapy Progress

Procedure

Psych Initial Visit

Psych Progress

Speech and Language Initial Evaluation

Speech and Language Progress Report

Speech and Language Treatment Note

Telehealth H&P

Telehealth SOAP

Therapist Initial Visit

Therapist Progress

Urgent Care