Detailed Clinical Note Formatting

Your complete note includes all of the templates you have charted, along with the patient's chief complaint (the reason for visit), vitals (and optionally any vitals history), their active and newly prescribed medications, allergies, and any ICD and billing codes that have been applied to the appointment. Where in the note these are located depends on whether you are charting using SOAP templates or H&P templates. It is important to keep the location of this content in mind when reordering your templates.

If you use SOAP templates:

  • The chief complaint will appear in its own section directly above the "H&P CC / History of Present Illness" template, or if the template was not used, directly above where it would have appeared.
  • The vitals will appear at the top of the "SOAP Objective" template.
  • The vitals history, if you have enabled it, will appear in its own section directly below the "SOAP Objective" template, or if the template was not used, directly below where it would have appeared.
  • The active medications and allergies will appear in the "Medications & Allergies" template.
  • The prescribed medications will appear at the bottom of the "SOAP Plan" template.
  • The ICD codes will appear at the bottom of the "SOAP Assessment" template.
  • The billing codes will appear directly above the prescribed medications in the "SOAP Plan" template.

If you use H&P templates:

  • The chief complaint will appear in its own section directly above the "H&P CC / History of Present Illness" template, or if the template was not used, directly above where it would have appeared.
  • The vitals will appear at the top of the "H&P Physical Exam" template.
  • The vitals history, if you have enabled it, will appear in its own section directly below the "H&P Physical Exam" template, or if the template was not used, directly below where it would have appeared.
  • The active medications and allergies will appear in the "Medications & Allergies" template.
  • The prescribed medications will appear at the bottom of the "H&P Plan" template.
  • The ICD codes will appear at the bottom of the "H&P Assessment" template.
  • The billing codes will appear directly above the prescribed medications in the "H&P Plan" template.

If you use both, or only custom templates:

If you use only custom templates, or at least as many SOAP templates as H&P templates, then your note will be formatted according to the "If you use SOAP templates" section. If you use more H&P templates than SOAP templates it will be formatted according to the "If you use H&P templates" section.

If you use both SOAP and H&P templates then the "SOAP Assessment" and "H&P Assessment" templates will be merged to prevent duplicate Assessment templates. The merged template will be placed where the "SOAP Assessment" template would appear, unless you used more H&P templates than SOAP templates, in which case it will be placed where the "H&P Assessment" template would appear. The same is done for the "SOAP Plan" and "H&P Plan" templates.

Since this can be confusing, using both SOAP and H&P templates is generally not recommended.

FreeDraw images:

By default, FreeDraw images are not attached to their templates but instead are appended to the clinical note on a new page. You can change this behavior in your account settings, under General > Clinical Notes, by unchecking "Move FreeDraws to End".

Was this article helpful?
0 out of 1 found this helpful
Have more questions? Submit a request

Comments

Powered by Zendesk