📝 Overview

Three default medical note templates are available—Basic SOAP, Simple SOAP, and Standard SOAP—each offering a different level of details across the SOAP notes. In addition to these defaults, you can create custom medical note templates using over 400 pre-existing fields or your own custom fields. Custom fields are created and managed in Settings and can be reused across medical notes, allowing you to standardize documentation while tailoring templates to your clinic’s specific workflows and data needs.

Video Overview of Medical Note & Custom Field Templates

📑 How to Create a Medical Note Template

Learn how to customize a medical note template for your clinic needs.

Click the arrow to learn more

Click on Settings
Click on Templates and select New Template
Complete the form that appears, including selecting Medical Note as the type, and click Save. You will be redirected to a blank medical note template
On the left side of the screen, click on the arrow icon next to each section to expand that section.
Click the checkbox of the field you want to include in your template (these fields may include custom fields). Your selected field will appear on the right side of the screen
Provide any desired default text for the applicable fields, and drag-and-drop the fields into the desired order from the square icon next to the name of the field
Click Save button to save your changes

💡 Each field that is included in the template can also be pre-populated with default notes to speed up the note-taking process in your exams. Simply enter in text within the medical note template, and that text will always appear when that medical note is used.

💡 You can duplicate any existing medical note to save you time. From within the medical note template you wish to duplicate, select Duplicate from the headers.

🐕 How to Add a New Section and Fields to a Patient's Active Medical Note

The needs for a particular patient's care and treatment may extend beyond the standardization that the general template provides, universally. To manage those cases, you can add new sections and fields to a patient's specific medical note on the fly. These edits will only take effect on that specific live medical note and not affect the main template.

💡 When working in a medical note for a patient, all fields in use will automatically save as you type. You will see a "Changes Saved" message periodically as you make edits to each field. Multiple users can work within a medical note at the same time on a patient's record, in different fields.

Click the arrow to learn how to add new sections & fields

Navigate to the patient's medical note
Click on the Medical Note tab and select Add Section
Click on the arrow next to the Section of interest to expand and view the subsections and various fields
Click the checkboxes to include the sections and fields of interest
Click Save

🔧 How to Edit & Lock a Medical Note

Learn how to edit an existing medical note template and a existing patient medical note.

Click the arrow to learn more

Editing a Patient's Existing Medical Note

There is the ability to edit an existing unlocked medical note and these changes are auto-saved in real-time. To edit an open medical note, simply navigate to the applicable medical note within the patient's profile and make the necessary changes.

Editing a Medical Note Template

Click the arrow to learn more

Navigate to Settings
Click on Templates > View Medical Notes Templates
Find the applicable medical note within the list, or search for the template within the search bar on the top right
Click Edit to the right of the medical note template
Make the needed edits, and click Save

Locking a Medical Note

⚠️ A locked medical note cannot be unlocked to ensure the integrity of the note's history. An amendment can be made if needed.

Click the arrow to learn more

Lock a Medical Note Manually

Navigate to the applicable medical note
Click on Lock Note in the navigation bar
Confirm your intent to lock the note by typing lock in the field that is shown

Locking Medical Notes Automatically

Click on Settings
Within your configuration list, find Lock Medical Notes and select the edit button on the right
Select the option to Automatically lock notes
Specify the number of days after which the medical note should be locked
Select "Save" when done

Add an Amendment to a Locked Medical Note

Navigate to the applicable medical note
Click on "Amendments" and select the option "Add Amendment"
Complete the form that appears and select "Save"
You can view the amendments from "View Amendments" under the "Amendments" tab

💡 Once the amendment is added, the number of amendments present on the medical note will show on the amendments tab as well as the summary of that medical note in the patient profile.

💬 How to Create & Work With Custom Fields

Custom fields are templates that are created in settings, and used within medical notes. These custom fields allow you to further customize your medical note templates for your clinic's needs.

Click the arrow to learn how to create and work with custom fields

How to Create a Custom Field Template

Click the arrow to learn more

Click on Settings
Click on Templates and select New Template
Complete the form that appears (be sure to select Custom Field as the type). If you would like to create a drop-down list, each picklist value should be on its own line (i.e., press enter after defining the value). The drop down list is optional.
Select the section that is applicable for this new field
Click Save + Done

How to Add a Custom Field to a Medical Note Template

Click the arrow to learn more

Click on Settings.
Click on Templates and select View Medical Notes
Click on the name of the applicable medical note
Navigate to the section to which your custom medical note was added - you may need to expand that section by clicking on the arrow next to the name of the section
Check the box next to the custom field to add it to your medical note template. Custom fields will always be on the bottom of the field list of the section
Click Save

💡 New custom fields can only be added to new medical note templates to preserve the integrity of existing medical notes.

Edit or Delete Custom Field

Click the arrow to learn more

Click on Settings
Click on Templates and select View Custom Fields
Click the Edit option on the far right of the applicable custom field
Make the desired changes and click Save

Deleting a Custom Field

Follow the same steps as editing a custom field, and select the "Delete" option which is to the right of the edit option. See screenshot above for an example.

💡 Edits made to a custom field will only apply to new uses of the applicable medical note template to preserve the integrity of existing medical notes. Deleted custom fields will no longer be available for use in new medical notes, and it will be deleted from existing medical note templates. However, existing medical notes that contain this field will not be impacted.

❓ Frequently Asked Questions (FAQs)

Find answers to common questions or additional details that may not be covered in the main instructions.

Click the arrow to view frequently asked questions