What Are Note Templates?
Note templates pre-populate evaluation notes with commonly used information, saving time during documentation.
Templates can be customized to specific conditions
ACL Post Op, Labrum Tear, Cervicalgia
Or more generalized locations:
Knee, Hip, Neck
Creating and Customizing the Template
1. Click gear icon.
2. Click "Note Templates"
3. Click "+ Note Template"
4. Name this template
5. Select evaluation as base template
6. Give this template a description.
7. Click "Save"
Subjective Section
8. Add a narrative where applicable
9. Select a pain measure.
10. Select applicable pain location
11. Click add to Note
12. Exit pane
13. Add applicable narratives to any blank text box
Treatments
14. Add treatments that you would typically perform during an evaluation as part of this rehab protocol.
15. Search for Treatments
16. Select applicable treatments
17.
18. Click Add
19. Add ROM Measures
20. Select range of motion location
21. Click Add
22. Exit Modal
23. Add Strength Measures
24. Select strength locations
25. Select any additional locations
26. Click "Add To Note"
27. Exit Modal
Special Tests
28. Add Special Tests
29. Search for special tests
30. Click Add
Objective Measures and Tests
31. Add Objective Measures and Tests
32, 33 & 34. Search for applicable objective measures and tests.
35.
Assessment
36. Add an Assessment Narrative
37. If possible, select the eval complexity
38. Select Yes
39. If possible, indicate rehab potential
40. Add a typical problems list
Plan of Care
41. Assign yourself as the primary provider.
42. Select the discipline type.
43. If the template is specific enough, you might even be able to select a primary diagnosis.
44. Search for DX code
45. Click "Add"
46. Continue
47. Click "+ Add procedure code"
48. Add any treatments that you plan on using during the course of this plan of care.
49. Click "Continue"
50. Add a duration.
51. Click the "Frequency" field.
52. Select /week or /month
53. Scroll back to the top and click save.
