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Using Templates Within Note

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Updated: 06/26/2024 | Views: 6401

Tebra templates provide an efficient and thorough way to document notes. You'll find templates available in various sections throughout the note. The easy-to-use checklist format generates text for the items you select and automatically adds them to the note.

A new clinical note can be created from three different locations: the patient's appointment on the Dashboard, the patient's Facesheet, and the Notes tab. It is recommended to create the note from the patient appointment to auto-populate appointment details.

Create Clinical Note

  1. Hover over the Platform icon and click on Dashboard. The Dashboard opens.
  2. Click the In Office tab. All patients with an in-office status displays.
  3. Click on the patient's appointment to view the appointment card.
  4. Click Create Clinical Note. The default note type opens.
    Note: If a clinical note for this appointment is in progress, the saved note opens.
    • To select a different note type, click the drop-down arrow and select the note.

icon_warning.png Important Note: Clinical logs the user out after 15 minutes of inactivity and does not save new notes in progress. To avoid losing the new note and enable autosave, click Save & Close. Then, click Open to start documenting the clinical note.

 Clinical_Appt_CreateNote.png

Use Template

The example clinical note used for this article is a standard SOAP note. Depending on the standard note type or custom note type selected to create a note, sections and templates of the note will vary.

  1. Click on a section header.
  2. Click Template. Depending on the section, the note, exam, or plan template opens.
 Clinical_UseTemplate_Access.png

General Template

  1. If necessary, click Default and select a different system or custom template. Then, click Select. Options will change based on the template selected.
  2. Click an item to expand additional options.
  3. Add the appropriate item(s) to the note:
    • If the item is a checkbox, click to select.
    • If the item requires a numeric value, click to select and use the number pad to enter the appropriate value. Click Save when finished.
    • If the item requires additional information, click to select and type the details in the blank field. Click Save when finished.
    • If the item requires a positive or negative, click plus to indicate yes/positive presence or click minus to indicate no/negative presence. When selected, the plus icon turns green and the minus icon turns red.
  4. Click Close when finished. The selected items populate in the section.
 Clinical_UseTemplate_Note.png

Exam Template

  1. If applicable, click Default and select a specific system or custom template. Then, click Select. Options will change based on the template selected.
    • To save the template as a favorite, hover over the template and click the star icon.
  2. The Exam type updates based on the template selected. If necessary, select a different Exam from the drop-down.
 Clinical_UseTemplate_Exam.png
  1. Click 1-Click normal exams to expand additional options.
  2. Click to select "Check All".
  3. If necessary, click to clear individual items to indicate the absence of normal findings.
 Clinical_UseTemplate_ExamCheckAll.png
  1. Click Pertinent Findings to expand additional options.
  2. Click an item to expand additional options.
  3. Add the appropriate item(s) to the note:
    • If the item is a checkbox, click to select.
    • If the item requires a numeric value, click to select and use the number pad to enter the appropriate value. Click Save when finished.
    • If the item requires additional information, click to select and type the details in the blank field. Click Save when finished.
    • If the item requires a positive or negative, click plus to indicate yes/positive presence or click minus to indicate no/negative presence. When selected, the plus icon turns green and the minus icon turns red.
  4. Click Close when finished. The selected items populate in the section.
 Clinical_UseTemplate_ExamSave.png

Plan Template

  1. If applicable, click Default and select a specific system or custom template. Then, click Select. Options will change based on the template selected.
    • To save the template as a favorite, hover over the template and click the star icon.
  2. Click an item to expand additional options.
    Note: Selecting Labs, Imaging, or Medications from the Default template will not generate a prescription or lab order.
  3. Add the appropriate item(s) to indicate the patient's treatment plan:
    • If the item is a checkbox, click to select.
    • If the item requires a numeric value, click to select and use the number pad to enter the appropriate value. Click Save when finished.
    • If the item requires additional information, click to select and type the details in the blank field. Click Save when finished.
    • If the item requires a positive or negative, click plus to indicate yes/positive presence or click minus to indicate no/negative presence. When selected, the plus icon turns green and the minus icon turns red.
  4. Click Close when finished. The selected items populate in the section.
 Clinical_UseTemplate_Plan.png