Note templates

Identifying information · Reason for referral · Presenting problem · History of the presenting problem · Psychiatric history · Medical history · Substance use · Family history · Social and developmental history · Mental status exam · Risk assessment · Diagnostic impression · Plan

Subjective · Objective · Assessment · Plan

Data · Assessment · Plan

Behavior · Intervention · Response · Plan

Goals · Intervention · Response · Plan

Session information · Participants · Presenting concerns · Relationship dynamics · Interventions used · Response · Risk · Plan

Session information · Participants · Presenting concerns · Family dynamics · Interventions used · Response · Risk · Plan

Group information · Session theme · Interventions used · Member participation · Member response · Risk · Plan

Chief complaint · Interval history · Current medications · Adherence and side effects · Mental status exam · Risk assessment · Assessment · Medication changes · Plan

Presenting problems · Diagnosis · Strengths · Goals · Measurable objectives · Interventions · Frequency and duration · Review date

Reason for assessment · Current ideation · Plan, intent and means · History of attempts · Risk factors · Protective factors · Risk level · Safety plan · Follow-up

Agenda · Mood check · Homework review · Session focus · Cognitive and behavioral interventions · Client response · New homework · Plan

Phase of treatment · Target · Negative and positive cognitions · SUD and VOC ratings · Processing summary · Closure · Plan

Session information · Who attended · Presenting concerns · School and development · Family context · Interventions used · Response · Risk · Plan

Dates of treatment · Reason for referral · Diagnoses · Treatment provided · Progress toward goals · Reason for discharge · Condition at discharge · Recommendations · Referrals

Concerns and goals · Medical history · Medications and allergies · Previous treatments · Skin assessment · Facial assessment · Options discussed · Consent · Plan

Pre-treatment assessment · Product and lot number · Dilution · Injection sites and units · Total units · Photographs · Aftercare given · Follow-up

Pre-treatment assessment · Product and lot number · Areas treated · Volume per area · Technique · Photographs · Aftercare given · Follow-up

Skin type · Pre-treatment assessment · Device and settings · Areas treated · Passes · Immediate response · Aftercare given · Follow-up

Skin type · Indication · Device and settings · Test patch · Areas treated · Immediate response · Aftercare given · Follow-up

Pre-treatment assessment · Device and needle depth · Topical products · Areas treated · Immediate response · Aftercare given · Follow-up

Skin type · Skin preparation · Peel agent and strength · Layers and contact time · Areas treated · Immediate response · Aftercare given · Follow-up

Treatment area · Measurements · Device and settings · Applicators and cycles · Photographs · Immediate response · Aftercare given · Follow-up

Pre-treatment assessment · Anesthesia · Thread type and lot number · Number of threads · Vectors and entry points · Immediate result · Aftercare given · Follow-up

Indication · Blood draw volume · Preparation method · Areas treated · Technique · Immediate response · Aftercare given · Follow-up

Time since treatment · Patient-reported result · Assessment · Photographs · Touch-up given · Product and units · Plan

Event description · Onset and timeline · Treatment involved · Assessment · Management · Escalation and referral · Patient communication · Follow-up

Procedure discussed · Medical history · Medications and allergies · Examination · Risks and alternatives discussed · Pre-operative instructions · Consent · Plan

Procedure summary · Pain · Wound and dressing · Swelling and bruising · Drains · Medications · Instructions given · Next review

Procedure summary · Healing progress · Wound check · Sutures · Swelling and bruising · Patient concerns · Instructions given · Next review

Chief complaint · Medical history · Dental history · Extraoral exam · Intraoral exam · Periodontal charting · Radiographs · Diagnosis · Treatment plan

Interval history · Medical history update · Extraoral and intraoral exam · Periodontal findings · Radiographs · Findings by tooth · Treatment plan · Recall interval

Medical history update · Periodontal findings · Scaling and polishing · Oral hygiene instruction · Fluoride · Findings for the dentist · Recall interval

Tooth and surfaces · Diagnosis · Anesthetic · Isolation · Preparation · Material and shade · Occlusion check · Post-operative instructions

Tooth · Diagnosis · Anesthetic · Preparation · Impression or scan · Shade · Temporary crown · Lab instructions · Next visit

Tooth · Indication · Consent · Anesthetic · Procedure · Hemostasis · Post-operative instructions · Medications · Follow-up

Tooth · Diagnosis · Anesthetic · Isolation · Access and canals · Working lengths · Instrumentation and irrigation · Obturation · Restoration · Follow-up

Medical history update · Probing depths · Bleeding on probing · Mobility and recession · Debridement · Home care review · Recall interval

Chief complaint · Medical history · Site assessment · Radiographs and imaging · Bone and soft tissue · Options discussed · Risks discussed · Treatment plan

Chief complaint · Pain history · Medical history · Examination · Tests · Radiographs · Diagnosis · Treatment given · Plan

Parent or guardian present · Medical history · Diet and habits · Extraoral and intraoral exam · Caries risk · Cleaning and fluoride · Guidance given · Recall interval

Risk factors · Extraoral exam · Lymph nodes · Intraoral soft tissue exam · Findings · Referral · Follow-up

Denture type · Fit and retention · Occlusion · Adjustments made · Soft tissue check · Care instructions · Next visit

Diagnosis summary · Options presented · Sequence and phasing · Fees discussed · Questions raised · Patient decision · Consent · Next steps

Health risk assessment · History update · Medications · Functional and cognitive screen · Depression screen · Vital signs · Preventive schedule · Advance care planning · Plan

Chief complaint · History of present illness · Review of systems · Examination · Assessment · Plan

Conditions reviewed · Interval history · Medications and adherence · Examination · Results reviewed · Assessment · Plan · Follow-up

Interval history · Glucose readings · Medications and adherence · Hypoglycemia · Foot exam · Eye and kidney screening · Results reviewed · Assessment · Plan

Interval history · Home readings · Medications and adherence · Side effects · Blood pressure today · Examination · Assessment · Plan

Visit type · Patient location · Chief complaint · History · Observed examination · Assessment · Plan · Follow-up

Current medication list · Adherence · Side effects · Interactions · Changes made · Patient education · Plan

Screenings due · Screenings completed · Results reviewed · Immunizations due · Counseling · Plan

Growth and vital signs · Development · Nutrition · Sleep · Examination · Immunizations · Anticipatory guidance · Next visit

Gestational age · Interval history · Vital signs · Fundal height · Fetal heart rate · Results reviewed · Counseling · Plan · Next visit

Sport · Medical history · Cardiac screening questions · Examination · Musculoskeletal exam · Clearance decision · Recommendations

Admission summary · Discharge diagnoses · Medication reconciliation · Pending results · Follow-up appointments · Services arranged · Plan

Functional status · Cognition · Mood · Falls and mobility · Medications · Nutrition · Social support · Goals of care · Plan

Tobacco use history · Readiness to quit · Previous attempts · Counseling given · Medication · Quit date · Follow-up

Vaccines due · Contraindication screen · Vaccine, lot number and site · Information given · Observation period · Next dose due

Treatment performed · What to expect · First 48 hours · Products to use · Products to avoid · Sun protection · When to call us · Next appointment