Notes Templates
Notes Templates are the practice forms clinicians pick when writing a visit note on the patient chart. Setup lives under Edit Practice → Notes Templates. Day-to-day use is chart → Clinical Notes (create draft, complete, send for review, approve/lock, addendum, fax, PDF). Templates can pull lab and imaging results into the note for documentation—they do not place lab or imaging orders. Ordering tests uses Lab Settings and Imaging Categories under Orders.
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Notes Templates
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What Notes Templates Are For
A Notes Template is a reusable structure for encounter documentation (sections and note options your practice defines). Staff choose a template when they create a Clinical Note so documentation stays consistent. Without templates and note options, creating a useful note is hard or empty.
Where Setup Lives (Practice)
Open Edit Practice → Notes Templates. List templates, star favourites, Create Template, or edit an existing one. Manage Note Options maintains the option library (categories and selectable text) that templates are built from. Practice templates are shared for the clinic—not tied to one location.
How to Create or Change a Template
Create Template → enter Template name → optionally mark favourite → select note options by category and format (for example paragraph vs detailed) → Save/Create. Edit updates the same pieces. Keep Manage Note Options current first—templates only have content if options exist. Super Admins and users with notes-template permissions can manage this; Manage Note Options may need its own permission.
Practice Templates vs Provider (SOAP) Templates
Practice Notes Templates (this tab) are clinic-wide. Provider SOAP / Free Text templates (often under Users / provider note templates) can be tied to a Visit Type Category and a specific provider—one template per visit-type category in that workflow. When staff create a note from the Dashboard with an appointment, the system may auto-pick a provider template that matches the visit type. Do not expect every Practice template to be “assigned” like a SOAP visit-type template.
Where Staff Use Templates (Patient Chart)
Open a patient → Clinical Notes → Create Note (or equivalent). Choose a practice template and/or provider template → the note form loads those sections → document the visit. Favourites help staff find common templates quickly. This is documentation—not Lab Orders or Imaging Orders.
Usage: Draft and Complete
Draft: fill the note and save as Draft while work continues (status Draft). Complete: finish documentation with Complete / save-and-sign style actions so the note is Complete. Completing a note tied to an appointment can update visit progress (for example Note Completed on the journey). Only edit freely while status and permissions allow.
Usage: Send for Review and Approve (Lock)
Send for Review: choose a reviewing doctor → note moves to Review and the reviewer is notified. Evaluate / Confirm & Approve: reviewer approves → Approved. In everyday language, approved notes are locked for normal editing. If the note is locked or past review-edit rules, use Add Addendum instead of rewriting silently. Mark as Error removes a note from normal use when something should not stand.
Usage: Addendum, Fax, and PDF
Add Addendum: add later corrections on Complete/Review/Approved notes when permitted (addendum can also go for review). Fax: Send fax / send clinical note by fax when note fax permission and outbound fax setup exist and status allows. PDF: Download PDF for printing or records. Password-protected PDFs may fail fax—export unprotected.
Usage with Labs and Imaging (Inside the Note)
Some template sections (for example Laboratory / Imaging / Diagnostic Test Results, or Labs and Imaging options) can auto-fill from chart lab and imaging data so the note summarizes results. That does not create an order. To order tests: chart → Orders → Lab Orders or Imaging Orders (catalogs from Lab Settings and Imaging Categories). Results are reviewed under chart Labs and Imaging. When faxing a lab or imaging order, staff can attach clinical notes as supplements to the fax package. Dashboard Results referral flows may also attach the most recent clinical note.
End-to-End: Visit Documentation Cases
Typical cases: (1) Room and take vitals → optional ROS → provider opens Clinical Notes → picks template → drafts during/after visit → Completes. (2) Mid-level documents → Send for Review → physician Approves. (3) After approve, new info arrives → Add Addendum. (4) Outside provider needs the note → Download PDF or Fax. (5) Visit included labs/imaging → order under Orders first or in parallel → when results return, open note template sections that pull Labs/Imaging, or reference them in the narrative → Complete. (6) Wrong note → Mark as Error per policy—do not leave a bad Approved note unaddressed.
What Notes Templates Are Not For
Not for placing lab or imaging orders (use Orders). Not for uploading general files (use Documents). Not for the practice fax console (main-menu Fax). Not the same as Lab Settings panels or Imaging Categories. Not IntelliMed AI drafts until content is finished in Clinical Notes.
Common Issues
Empty create / no content: configure Manage Note Options and publish templates. Wrong template on Dashboard create: provider visit-type SOAP may be required—practice templates do not always auto-match visit type. Cannot edit after approve: use Addendum. Looking for order buttons in Notes: go to Orders. Labs/Imaging not filling the note: results not on the chart yet, or template lacks those options. Fax greyed out: status, permission, or fax setup. Confused Practice vs Provider templates: see the article above.