We work with organizations globally, and in that time we've fine tuned a handful section templates that organizations can use to build their own template sections. The following is our most frequently used sections in documentation templates to help you to use the templates that will be the most effective for your team.
Patient History
The following section templates focus on the patient’s medical background, family history, lifestyle factors, and current medications. The provide context for understanding the patient’s overall health, risk factors, and any pre-existing conditions that might influence the current clinical presentation. Important social determinants, such as alcohol use and social history, are also captured here.
Past Medical History - the patient's previous medical conditions
Past Medical and Surgical History - combined account of the patient's medical and surgical history
Family History - documentation of medical conditions present in the patient’s family that could influence their health risks
Social History - social factors, including smoking, alcohol, occupation, education, work capability, living situation and other social issues
Alcohol - the patient's current alcohol use, including the type and amount of alcohol used daily
Allergies - known drug allergies and other allergies, along with the reactions
Medications - list of medications the patient is currently taking, including dosages and frequency
Subjective Information
The following section templates cover the patient’s own description of their symptoms, concerns, and experiences. they includes the chief complaint, the detailed history of the present illness, and a systematic review of symptoms across different body systems to identify related issues the patient might not have mentioned initially.
Chief Complaint - A brief statement describing the main reason for the patient's visit
History of Present Illness (HPI) - detailed description of the patient's experience
Subjective - similar to HPI, but broader in scope and suitable for a simpler SOAP-style note. Includes a detailed narrative of symptoms leading up to the current visit, including onset, duration, and any treatments attempted
Review of Systems - A systematic review of body systems to identify any other symptoms the patient may be experiencing
Objective Information
These section templates document measurable, observed, or examined clinical findings gathered during the encounter. They includes vital signs, physical examination results, and other observable data that support the clinical evaluation.
Physical Examination w/o Vitals - An evaluation of the patients physical examination without the inclusion of vital signs
Objective - the detailed results of the physical examination
Assessment and Plan
The following section templates outline the healthcare provider’s clinical interpretation, including diagnoses, differential diagnoses, and the proposed treatment or management plan. The plan may include diagnostic tests, follow-up instructions, and referrals if needed. It combines clinical reasoning and next steps for care.
Plan - the collection of orders that the clinician suggests, including studies, procedures, admissions, observations planned, and other activities
Assessment - a brief summary of the doctor's diagnostic considerations
Assessment + Plan - A diagnosis or evaluation of the patient's condition and the proposed treatment plan