Note Types and Default Sections
Tebra 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 |
Consultation |
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 |
Discharge Summary |
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 |
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 |