Templates
Note templates
Sixty note structures, free to use, in any tool or none.
Mental health
In Solanto at launch
Intake (biopsychosocial)
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
Mental health
In Solanto at launch
SOAP note
Subjective · Objective · Assessment · Plan
Mental health
DAP note
Data · Assessment · Plan
Mental health
BIRP note
Behavior · Intervention · Response · Plan
Mental health
GIRP note
Goals · Intervention · Response · Plan
Mental health
Individual therapy progress note
Session information · Presenting concerns · Interventions used · Client response · Progress toward goals · Risk · Plan
Mental health
Couples therapy note
Session information · Participants · Presenting concerns · Relationship dynamics · Interventions used · Response · Risk · Plan
Mental health
Family therapy note
Session information · Participants · Presenting concerns · Family dynamics · Interventions used · Response · Risk · Plan
Mental health
Group therapy note
Group information · Session theme · Interventions used · Member participation · Member response · Risk · Plan
Mental health
Psychiatric medication management
Chief complaint · Interval history · Current medications · Adherence and side effects · Mental status exam · Risk assessment · Assessment · Medication changes · Plan
Mental health
Treatment plan
Presenting problems · Diagnosis · Strengths · Goals · Measurable objectives · Interventions · Frequency and duration · Review date
Mental health
Risk assessment
Reason for assessment · Current ideation · Plan, intent and means · History of attempts · Risk factors · Protective factors · Risk level · Safety plan · Follow-up
Mental health
CBT session note
Agenda · Mood check · Homework review · Session focus · Cognitive and behavioral interventions · Client response · New homework · Plan
Mental health
EMDR session note
Phase of treatment · Target · Negative and positive cognitions · SUD and VOC ratings · Processing summary · Closure · Plan
Mental health
Child and adolescent note
Session information · Who attended · Presenting concerns · School and development · Family context · Interventions used · Response · Risk · Plan
Mental health
Discharge summary
Dates of treatment · Reason for referral · Diagnoses · Treatment provided · Progress toward goals · Reason for discharge · Condition at discharge · Recommendations · Referrals
Aesthetics
In Solanto at launch
New patient consultation
Concerns and goals · Medical history · Medications and allergies · Previous treatments · Skin assessment · Facial assessment · Options discussed · Consent · Plan
Aesthetics
In Solanto at launch
Neurotoxin treatment
Pre-treatment assessment · Product and lot number · Dilution · Injection sites and units · Total units · Photographs · Aftercare given · Follow-up
Aesthetics
Dermal filler treatment
Pre-treatment assessment · Product and lot number · Areas treated · Volume per area · Technique · Photographs · Aftercare given · Follow-up
Aesthetics
Laser resurfacing
Skin type · Pre-treatment assessment · Device and settings · Areas treated · Passes · Immediate response · Aftercare given · Follow-up
Aesthetics
IPL treatment
Skin type · Indication · Device and settings · Test patch · Areas treated · Immediate response · Aftercare given · Follow-up
Aesthetics
Microneedling
Pre-treatment assessment · Device and needle depth · Topical products · Areas treated · Immediate response · Aftercare given · Follow-up
Aesthetics
Chemical peel
Skin type · Skin preparation · Peel agent and strength · Layers and contact time · Areas treated · Immediate response · Aftercare given · Follow-up
Aesthetics
Body contouring
Treatment area · Measurements · Device and settings · Applicators and cycles · Photographs · Immediate response · Aftercare given · Follow-up
Aesthetics
Thread lift
Pre-treatment assessment · Anesthesia · Thread type and lot number · Number of threads · Vectors and entry points · Immediate result · Aftercare given · Follow-up
Aesthetics
PRP treatment
Indication · Blood draw volume · Preparation method · Areas treated · Technique · Immediate response · Aftercare given · Follow-up
Aesthetics
Follow-up and touch-up
Time since treatment · Patient-reported result · Assessment · Photographs · Touch-up given · Product and units · Plan
Aesthetics
Adverse event note
Event description · Onset and timeline · Treatment involved · Assessment · Management · Escalation and referral · Patient communication · Follow-up
Aesthetics
Pre-operative consultation
Procedure discussed · Medical history · Medications and allergies · Examination · Risks and alternatives discussed · Pre-operative instructions · Consent · Plan
Aesthetics
Post-operative day one
Procedure summary · Pain · Wound and dressing · Swelling and bruising · Drains · Medications · Instructions given · Next review
Aesthetics
Post-operative week one
Procedure summary · Healing progress · Wound check · Sutures · Swelling and bruising · Patient concerns · Instructions given · Next review
Aesthetics
Photo documentation
Photo consent and permitted uses · Treatment stage · Views taken · Lighting and camera settings · Areas photographed · Comparison notes
Dental
In Solanto at launch
New patient exam
Chief complaint · Medical history · Dental history · Extraoral exam · Intraoral exam · Periodontal charting · Radiographs · Diagnosis · Treatment plan
Dental
Periodic exam
Interval history · Medical history update · Extraoral and intraoral exam · Periodontal findings · Radiographs · Findings by tooth · Treatment plan · Recall interval
Dental
Hygiene visit
Medical history update · Periodontal findings · Scaling and polishing · Oral hygiene instruction · Fluoride · Findings for the dentist · Recall interval
Dental
Restorative visit
Tooth and surfaces · Diagnosis · Anesthetic · Isolation · Preparation · Material and shade · Occlusion check · Post-operative instructions
Dental
Crown preparation
Tooth · Diagnosis · Anesthetic · Preparation · Impression or scan · Shade · Temporary crown · Lab instructions · Next visit
Dental
Extraction
Tooth · Indication · Consent · Anesthetic · Procedure · Hemostasis · Post-operative instructions · Medications · Follow-up
Dental
Endodontic treatment
Tooth · Diagnosis · Anesthetic · Isolation · Access and canals · Working lengths · Instrumentation and irrigation · Obturation · Restoration · Follow-up
Dental
Periodontal maintenance
Medical history update · Probing depths · Bleeding on probing · Mobility and recession · Debridement · Home care review · Recall interval
Dental
Implant consultation
Chief complaint · Medical history · Site assessment · Radiographs and imaging · Bone and soft tissue · Options discussed · Risks discussed · Treatment plan
Dental
Orthodontic adjustment
Appliance · Compliance · Oral hygiene · Changes made · Wires and elastics · Instructions given · Next visit
Dental
Emergency and pain visit
Chief complaint · Pain history · Medical history · Examination · Tests · Radiographs · Diagnosis · Treatment given · Plan
Dental
Pediatric exam
Parent or guardian present · Medical history · Diet and habits · Extraoral and intraoral exam · Caries risk · Cleaning and fluoride · Guidance given · Recall interval
Dental
Oral cancer screening
Risk factors · Extraoral exam · Lymph nodes · Intraoral soft tissue exam · Findings · Referral · Follow-up
Dental
Denture fitting
Denture type · Fit and retention · Occlusion · Adjustments made · Soft tissue check · Care instructions · Next visit
Dental
Treatment plan presentation
Diagnosis summary · Options presented · Sequence and phasing · Fees discussed · Questions raised · Patient decision · Consent · Next steps
Primary care
Annual wellness visit
Health risk assessment · History update · Medications · Functional and cognitive screen · Depression screen · Vital signs · Preventive schedule · Advance care planning · Plan
Primary care
In Solanto at launch
Acute visit
Chief complaint · History of present illness · Review of systems · Examination · Assessment · Plan
Primary care
Chronic disease follow-up
Conditions reviewed · Interval history · Medications and adherence · Examination · Results reviewed · Assessment · Plan · Follow-up
Primary care
Diabetes management
Interval history · Glucose readings · Medications and adherence · Hypoglycemia · Foot exam · Eye and kidney screening · Results reviewed · Assessment · Plan
Primary care
Hypertension follow-up
Interval history · Home readings · Medications and adherence · Side effects · Blood pressure today · Examination · Assessment · Plan
Primary care
Telehealth visit
Visit type · Patient location · Chief complaint · History · Observed examination · Assessment · Plan · Follow-up
Primary care
Medication review
Current medication list · Adherence · Side effects · Interactions · Changes made · Patient education · Plan
Primary care
Preventive screening
Screenings due · Screenings completed · Results reviewed · Immunizations due · Counseling · Plan
Primary care
Well child visit
Growth and vital signs · Development · Nutrition · Sleep · Examination · Immunizations · Anticipatory guidance · Next visit
Primary care
Prenatal visit
Gestational age · Interval history · Vital signs · Fundal height · Fetal heart rate · Results reviewed · Counseling · Plan · Next visit
Primary care
Sports physical
Sport · Medical history · Cardiac screening questions · Examination · Musculoskeletal exam · Clearance decision · Recommendations
Primary care
Transition of care
Admission summary · Discharge diagnoses · Medication reconciliation · Pending results · Follow-up appointments · Services arranged · Plan
Primary care
Geriatric assessment
Functional status · Cognition · Mood · Falls and mobility · Medications · Nutrition · Social support · Goals of care · Plan
Primary care
Smoking cessation
Tobacco use history · Readiness to quit · Previous attempts · Counseling given · Medication · Quit date · Follow-up
Primary care
Immunization visit
Vaccines due · Contraindication screen · Vaccine, lot number and site · Information given · Observation period · Next dose due