Medical Note Templates Library
Browse all templates by category and specialty. Copy-ready sections with HPI, ROS, PE, Assessment & Plan for your documentation needs.
Administrative — Against Medical Advice (AMA) Discharge Form
Discharge Against Medical Advice (AMA) form. Document patient refusal of recommended care and release of liability. Critical risk management tool for hospitals and clinics.
Administrative — DOT Medical Exam Report (Commercial Driver)
DOT Physical Form / Medical Examination Report for Commercial Driver Fitness Determination (FMCSA). Standard check-off form for CDL physicals.
Administrative — Good Faith Estimate (No Surprises Act)
Good Faith Estimate (GFE) form for self-pay and uninsured patients. Compliant with the No Surprises Act. Document expected charges for scheduled services.
Administrative — HIPAA Release Form
Standard HIPAA Authorization Form for release of medical records. HIPAA compliant template for patients to authorize sharing of PHI with family or other providers.
Administrative — Jury Duty Excuse Letter
Formal medical excuse letter for jury duty exemption. Document medical conditions that prevent service. For physicians and providers.
Administrative — Living Will (Advance Directive)
Advance Medical Directive (Living Will) template. Document end-of-life care preferences, life support, and hydration/nutrition choices. Essential for patient care planning.
Medical Power of Attorney Template
Medical Power of Attorney form. Designate a healthcare agent to make medical decisions if you become incapacitated. Essential legal document for advanced care planning.
Medicare ABN Template: Advance Beneficiary Notice
Standard Medicare ABN Form (CMS-R-131 style). Use this text to notify Medicare beneficiaries of likely denial of services and potential financial liability. Compliance requirement.
Administrative — Opioid Treatment Agreement (Pain Contract)
Controlled Substance Agreement / Pain Management Contract. Standard legal agreement between provider and patient for long-term opioid therapy. DEA/CDC guidelines.
Administrative — Generic Procedure Informed Consent
Universal Informed Consent form for minor medical procedures (biopsy, injection, I&D). Document risks, benefits, and alternatives. Legal requirement.
Superbill Template: Medical Receipt for Insurance
Standard medical Superbill template for patient reimbursement. Includes fields for CPT codes, diagnosis codes (ICD-10), provider NPI, and facility location. Essential for out-of-network providers.
Administrative — Telehealth Informed Consent
Informed consent form for telemedicine services. Covers technology risks, privacy, and limitations of remote exams. Legal requirement for virtual care.
Workers' Comp First Report of Injury Template
Standard Workers' Comp First Report of Injury form. Document work-related accidents, injury details, and initial treatment. Essential for occupational health claims.
Chiropractic — New Patient Exam Template
The Chiropractic New Patient Exam Template is designed for chiropractors performing initial evaluations. This template documents the 'PART' requirements for Medicare (Pain/Tenderness, Asymmetry, ROM, Tissue Tone), analysis of spinal subluxations, orthopedic testing, and calculation of a care plan. Includes sections for spinal listing and adjustment technique planning. Ideal for chiropractic clinics.
Dental — Comprehensive Exam Template (D0150)
Standard Dental Comprehensive Exam note template. Includes extraoral/intraoral exam, perio charting, restorative findings, and treatment planning. Suitable for general dentists and specialists.
Infectious Disease — New Patient Consultation Template
The Infectious Disease Consultation Template is designed for ID specialists evaluating patients for complex infections, FUO (Fever of Unknown Origin), or post-operative complications. This template documents detailed exposure history, travel history, antibiotic usage, culture results, and antimicrobial stewardship planning. Includes sections for HIV/immunocompromised status assessment and IV antibiotic management. Ideal for hospital consults and ID clinic visits.
Nutrition — Counseling & Dietitian Note Template
The Nutrition Counseling Template is designed for Registered Dietitians (RD) and nutritionists providing medical nutrition therapy (MNT). This template documents 24-hour dietary recall, weight history, nutritional assessment, estimated energy needs, and specific dietary interventions. Supports billing for CPT codes 97802/97803. Ideal for weight management, diabetes education, and clinical nutrition.
Occupational Therapy — Initial Evaluation Template
Comprehensive Occupational Therapy (OT) Initial Evaluation template. Document ADLs, IADLs, range of motion, strength, sensation, and functional goals. Ideal for outpatient, rehab, and home health settings.
Palliative Care — Consultation Template
The Palliative Care Consultation Template is designed for palliative care teams evaluating patients with serious, life-limiting illnesses. This template documents symptom burden (pain, dyspnea, nausea), goals of care discussions, code status (DNR/DNI), advance directives, and psychosocial support needs. It supports interdisciplinary documentation for improving quality of life and aligning treatment with patient values. Ideal for inpatient consults and hospice intake.
Physical Therapy — Initial Evaluation Template
The Physical Therapy Initial Evaluation Template is designed for physical therapists evaluating new patients for musculoskeletal or neurological conditions. This template documents subjective history, pain levels, functional limitations, objective measurements (ROM, strength, special tests), detailed assessment, and plan of care with functional goals. Supports Medicare requirements for G-codes and functional reporting. Ideal for outpatient PT clinics.
Plastic Surgery — New Patient Consultation Template
The Plastic Surgery New Patient Consultation Template is designed for plastic surgeons evaluating patients for cosmetic or reconstructive procedures. This template documents patient goals, medical history including prior surgeries and scarring, detailed physical examination, and procedural planning. It supports both aesthetic and reconstructive billing requirements (when applicable) and includes sections for photography consent and perioperative risk assessment. Ideal for plastic surgery practices and medical spas.
Podiatry — Detailed Foot Examination Template
The Podiatry Foot Examination Template is designed for podiatrists evaluating patients for diabetic foot care, nail pathology, or musculoskeletal foot pain. This template captures vascular status (pulses), neurological status (monofilament), dermatological findings (nails, calluses, ulcers), and musculoskeletal exam. Supports billing for diabetic foot care and routine foot care (when qualified). Ideal for podiatry practices.
Sleep Medicine — Sleep Evaluation Template
The Sleep Medicine Evaluation Template is designed for sleep specialists, pulmonologists, and neurologists evaluating patients for sleep disorders. This template captures sleep history, Epworth Sleepiness Scale, STOP-BANG score, CPAP history, and detailed sleep hygiene review. It supports documentation for polysomnography (PSG) orders and CPAP compliance. Ideal for sleep clinics and home sleep testing evaluation.
Speech Therapy — Evaluation Template
The Speech Therapy Evaluation Template is designed for Speech-Language Pathologists (SLPs) evaluating patients for speech, language, cognitive-communication, or swallowing disorders (dysphagia). This template documents receptive/expressive language, speech motor function, voice quality, cognitive status, and swallowing safety. Supports Medicare requirements for functional reporting and goal setting. Ideal for outpatient clinics, hospitals, and SNFs.
Wound Care — Progress Note Template
The Wound Care Progress Note Template is designed for wound care specialists, nurses, and physical therapists managing chronic or acute wounds. This template captures detailed wound measurements (L x W x D), tissue types (granulation, necrotic), drainage (exudate), periwound condition, and response to treatment. Supports documentation for ulcers (venous, arterial, diabetic, pressure) and surgical wounds. Includes sections for debridement and dressing changes.
Allergy/Immunology — Immunotherapy Follow-up Template
The Immunotherapy Follow-up Template is designed for allergists monitoring patients on allergy immunotherapy. This template documents injection tolerance, symptom control, and treatment progression. Supports appropriate billing for immunotherapy supervision and includes sections for reaction documentation, dose advancement decisions, and efficacy assessment. Ideal for allergy practices administering subcutaneous or sublingual immunotherapy.
Allergy/Immunology — New Patient Consultation Template
The Allergy/Immunology New Patient Consultation Template is designed for allergists evaluating patients with allergic and immunologic conditions. This comprehensive template documents allergy history, symptom patterns, skin testing results, and immunotherapy planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for allergen identification, asthma assessment, anaphylaxis risk evaluation, and treatment recommendations. Ideal for allergy practices and clinical immunology centers.
Cardiology — Atrial Fibrillation Management Template
The Atrial Fibrillation Management Template is designed for cardiologists and electrophysiologists managing patients with atrial fibrillation or flutter. This template documents rhythm assessment, stroke risk stratification, anticoagulation management, rate/rhythm control strategies, and procedural planning. Supports appropriate billing for E/M services and includes CHA2DS2-VASc and HAS-BLED scoring, medication optimization, and cardioversion or ablation planning. Ideal for cardiology practices, EP clinics, and anticoagulation management services.
Cardiology — Chest Pain Evaluation Template
The Chest Pain Evaluation Template is designed for cardiologists, emergency physicians, and internists evaluating patients presenting with chest pain. This template documents the comprehensive workup required for risk stratification, including detailed pain characterization, cardiovascular risk factors, physical examination findings, and diagnostic test interpretation. The template supports appropriate billing for evaluation and management (E/M) services and includes sections for chief complaint characterization, cardiovascular history and risk factors, associated symptoms, physical examination with cardiac focus, ECG interpretation, troponin and biomarker results, risk stratification assessment, and disposition planning. Ideal for cardiology practices, emergency departments, hospitalist services, and urgent care settings evaluating chest pain.
Cardiology — Heart Failure Follow-Up Template
The Heart Failure Follow-Up Template is designed for cardiologists managing patients with established heart failure. This template documents interval changes, symptom assessment, medication optimization, and care coordination. Supports appropriate billing for established patient visits (99213-99215) and includes sections for symptom review, volume status assessment, medication reconciliation, diagnostic monitoring, and guideline-directed medical therapy optimization. Ideal for outpatient cardiology practices, heart failure clinics, and advanced heart failure programs.
Cardiology — New Patient Consultation Template
The New Patient Consultation Template is designed for cardiologists seeing patients referred for cardiac evaluation. This comprehensive template documents the initial cardiovascular assessment including detailed history, risk factor evaluation, physical examination with cardiac focus, review of diagnostic studies, and development of a cardiac care plan. The template supports appropriate billing for new patient consultations (99243-99245) and includes sections for referral reason and source, comprehensive cardiac history, cardiovascular risk factors, medication reconciliation, physical examination, diagnostic review, and management recommendations. Ideal for outpatient cardiology practices, academic cardiology clinics, and consultative cardiology services.
Cardiology — Preoperative Cardiac Clearance Template
The Preoperative Cardiac Clearance Template is designed for cardiologists evaluating patients for non-cardiac surgery. This template documents surgical risk assessment, functional capacity evaluation, cardiac history review, and perioperative management recommendations following ACC/AHA guidelines. Supports appropriate billing for preoperative consultations (99243-99245) and includes sections for surgical risk stratification, functional capacity assessment, active cardiac conditions, and perioperative medication management. Ideal for consultative cardiology practices and preoperative assessment clinics.
Clinical Note Template — Patient Encounter Documentation
The Clinical Note Template provides a comprehensive framework for documenting patient encounters across all healthcare settings. This universal template supports physicians, nurse practitioners, and physician assistants in capturing chief complaint, clinical history, examination findings, diagnostic reasoning, and treatment planning. Designed for flexibility, this template adapts to office visits, hospital encounters, urgent care, and telehealth appointments. The format aligns with E/M documentation requirements (99202-99215, 99221-99223) and supports accurate coding while ensuring thorough patient care documentation. Key sections include patient presentation, comprehensive history, physical examination by system, diagnostic assessment, clinical decision-making, and detailed care plan. Ideal for primary care, specialty practices, hospital medicine, and any clinical setting requiring structured medical documentation.
Critical Care Documentation Template — 99291/99292 Billing
The Critical Care Documentation Template provides comprehensive guidance for documenting critical care services (CPT 99291-99292) for critically ill or injured patients. Critical care requires specific documentation elements including critical illness definition, constant physician attention, and detailed time tracking. This template covers the documentation requirements for billing 99291 (first 30-74 minutes) and 99292 (each additional 30 minutes), what conditions qualify as critical illness, time tracking requirements, and procedures bundled vs separately billable.
Daily Progress Note Template — Hospital Rounding Documentation
The Daily Progress Note Template is optimized for hospitalists, residents, and attending physicians documenting daily inpatient rounds. This efficient template captures the essential elements of each hospital day including overnight events, morning assessment, interval changes, and daily care plan updates. Designed for high-volume hospital settings where efficiency matters, this template supports appropriate billing for subsequent hospital care (CPT 99231-99233) while maintaining thorough documentation. Key features include quick-reference vital sign trends, problem-based organization for complex patients, discharge planning tracking, and medication reconciliation. The format integrates seamlessly with electronic health records and supports verbal sign-out preparation. Ideal for academic medical centers, community hospitals, hospitalist programs, and teaching services managing multiple daily progress notes.
Dermatology — General Consultation Template
The General Dermatology Consultation Template is designed for dermatologists evaluating patients with skin, hair, and nail complaints. This comprehensive template documents detailed lesion description using standardized dermatological terminology, differential diagnosis, diagnostic workup, and treatment planning. Supports appropriate billing for new and established patient visits and includes sections for chief complaint, dermatological history, lesion morphology description, dermoscopic findings, biopsy documentation, and management plans. Ideal for general dermatology practices, academic dermatology clinics, and teledermatology services.
Dermatology — Procedure Note Template
The Dermatology Procedure Note Template is designed for dermatologists performing office-based procedures including biopsies, excisions, destructions, and repairs. This template documents indication, consent, technique, specimen handling, and wound care instructions. Supports appropriate billing for procedural services and includes sections for pre-procedure assessment, anesthesia, procedure technique, specimen disposition, complications, and post-procedure instructions. Ideal for general dermatology practices, Mohs surgery centers, and dermatologic surgery units.
Dermatology — Skin Cancer Screening Template
The Skin Cancer Screening Template is designed for dermatologists performing full body skin examinations for skin cancer detection. This template documents comprehensive screening findings, risk factor assessment, suspicious lesion documentation, dermoscopic evaluation, and biopsy decisions. Supports appropriate billing for preventive services and includes sections for patient risk stratification, total body skin exam findings, ABCDE criteria documentation, dermoscopy, and surveillance planning. Ideal for general dermatology practices, skin cancer screening clinics, and melanoma surveillance programs.
E/M Coding Documentation Guide — Office Visit Billing Template
The E/M Coding Documentation Guide helps physicians and medical coders understand evaluation and management documentation requirements for accurate billing. This comprehensive guide covers medical decision making (MDM) complexity levels, time-based billing documentation, new vs established patient criteria, and documentation requirements for each E/M code level (99202-99215). Includes practical examples of documentation that supports straightforward, low, moderate, and high complexity MDM. The guide addresses common documentation pitfalls, audit triggers, and strategies for appropriate code selection. Essential for primary care providers, specialists, hospitalists, and any clinician billing office/outpatient E/M services.
Emergency Medicine — General ED Note Template
The General ED Note Template is designed for emergency physicians evaluating patients with a wide range of presenting complaints. This comprehensive template documents chief complaint, triage assessment, history and physical examination, diagnostic workup, medical decision-making, and disposition planning. Supports appropriate billing for E/M services (99281-99285) and critical care and includes sections for chief complaint, HPI, review of systems, physical examination, diagnostic results, differential diagnosis, and disposition. Ideal for emergency departments, freestanding EDs, and urgent care centers handling acute presentations.
Emergency Medicine — Trauma Evaluation Template
The Trauma Evaluation Template is designed for emergency physicians and trauma surgeons evaluating patients with traumatic injuries. This template documents mechanism of injury, primary and secondary survey findings, imaging interpretation, and trauma team activation decisions following ATLS principles. Supports appropriate billing for E/M services and critical care and includes sections for prehospital information, ABCDE assessment, injury inventory, and disposition to OR, ICU, or trauma bay management. Ideal for trauma centers, emergency departments, and acute care facilities.
Endocrinology — Diabetes Follow-up Template
The Diabetes Follow-up Template is designed for endocrinologists managing patients with diabetes mellitus. This template documents glycemic control, medication adjustments, complication screening, and lifestyle modifications. Supports appropriate billing for established patient visits and includes A1c trending, CGM data interpretation, and insulin dose optimization. Ideal for diabetes centers and endocrinology practices.
Endocrinology — New Patient Consultation Template
The Endocrinology New Patient Consultation Template is designed for endocrinologists evaluating patients with hormonal disorders. This comprehensive template documents diabetes management, thyroid disease, adrenal disorders, and metabolic bone disease. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for glycemic control assessment, thyroid nodule evaluation, pituitary workup, and osteoporosis management. Ideal for endocrinology practices and diabetes centers.
ENT — Hearing Evaluation Template
The Hearing Evaluation Template is designed for otolaryngologists and audiologists assessing patients with hearing concerns. This template documents audiometric findings, hearing aid candidacy, and cochlear implant evaluation. Supports appropriate billing for hearing assessments and includes sections for audiogram interpretation, speech recognition scoring, tympanometry, and rehabilitation planning. Ideal for otology practices, hearing centers, and cochlear implant programs.
ENT — New Patient Consultation Template
The ENT New Patient Consultation Template is designed for otolaryngologists evaluating patients with ear, nose, and throat complaints. This comprehensive template documents complete head and neck examination, audiometric assessment, endoscopic findings, and treatment planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for hearing evaluation, sinonasal assessment, laryngeal examination, and head/neck mass workup. Ideal for general ENT practices, otology clinics, and head/neck surgery centers.
Gastroenterology — New Patient Consultation Template
The Gastroenterology New Patient Consultation Template is designed for gastroenterologists evaluating patients with digestive disorders. This comprehensive template documents GI-specific history, abdominal examination, diagnostic workup, and management planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for symptom characterization, alarm symptom screening, medication reconciliation, endoscopy planning, and follow-up coordination. Ideal for general GI practices, hepatology clinics, and IBD centers.
Modifier Documentation Guide — CPT Billing Modifiers
The Modifier Documentation Guide helps physicians and medical billers understand when and how to use CPT modifiers for accurate reimbursement. This comprehensive guide covers the most common modifiers including modifier 25 (significant, separately identifiable E/M), modifier 59 (distinct procedural service), modifier 24 (unrelated E/M during postoperative period), and modifier 57 (decision for surgery). Each modifier includes documentation requirements, appropriate use examples, and common errors to avoid. Understanding modifier usage prevents claim denials, ensures appropriate reimbursement, and maintains compliance with payer policies.
Nephrology — Dialysis Follow-up Template
The Dialysis Follow-up Template is designed for nephrologists managing patients on hemodialysis or peritoneal dialysis. This template documents dialysis adequacy, access function, volume status, and CKD-MBD management. Supports appropriate billing for dialysis monthly visits and includes Kt/V assessment, dry weight optimization, and complication monitoring. Ideal for dialysis centers and outpatient nephrology practices.
Nephrology — New Patient Consultation Template
The Nephrology New Patient Consultation Template is designed for nephrologists evaluating patients with kidney disease. This comprehensive template documents CKD staging, proteinuria assessment, electrolyte abnormalities, and renal replacement therapy planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for GFR calculation, urinalysis interpretation, dialysis access planning, and transplant evaluation. Ideal for general nephrology practices, dialysis centers, and transplant programs.
Neurology — Headache Evaluation Template
The Headache Evaluation Template is designed for neurologists and headache specialists evaluating patients with primary and secondary headache disorders. This template documents headache characteristics, red flag screening, trigger identification, and treatment optimization. Supports appropriate billing for E/M services and includes ICHD-3 criteria assessment, medication overuse evaluation, acute and preventive treatment planning, and disability impact measurement. Ideal for headache clinics, neurology practices, and primary care providers managing complex headache patients.
Neurology — New Patient Consultation Template
The Neurology New Patient Consultation Template is designed for neurologists evaluating patients with neurological complaints. This comprehensive template documents detailed neurological history, comprehensive neurological examination, diagnostic workup, and management planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for headache characterization, seizure history, cognitive assessment, cranial nerve examination, motor/sensory evaluation, and differential diagnosis. Ideal for general neurology practices, headache clinics, and academic neurology services.
Oncology — Chemotherapy Follow-up Template
The Chemotherapy Follow-up Template is designed for oncologists managing patients on active systemic cancer therapy. This template documents treatment tolerance, toxicity grading, response assessment, and dose modifications. Supports appropriate billing for established patient visits and includes CTCAE toxicity grading, lab monitoring, symptom management, and treatment continuation decisions. Ideal for medical oncology infusion centers and cancer treatment facilities.
Oncology — New Patient Consultation Template
The Oncology New Patient Consultation Template is designed for oncologists evaluating patients with newly diagnosed or suspected malignancies. This comprehensive template documents cancer staging, performance status, treatment planning, and supportive care needs. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for pathology review, staging workup, multidisciplinary discussion, and treatment goal setting. Ideal for medical oncology practices, cancer centers, and hematology-oncology clinics.
Ophthalmology — Cataract Evaluation Template
The Cataract Evaluation Template is designed for ophthalmologists assessing patients for cataract surgery. This template documents visual function, lens opacity grading, IOL calculations, and surgical planning. Supports appropriate billing for pre-operative evaluation and includes sections for functional impairment assessment, biometry, IOL selection, and informed consent. Ideal for cataract surgeons and comprehensive ophthalmology practices.
Ophthalmology — Comprehensive Eye Examination Template
The Comprehensive Eye Examination Template is designed for ophthalmologists evaluating patients with visual complaints. This template documents complete ocular history, anterior and posterior segment examination, and management planning. Supports appropriate billing for comprehensive eye exams (92004, 92014) and includes sections for visual acuity, refraction, slit lamp examination, fundoscopy, and IOP measurement. Ideal for general ophthalmology practices and comprehensive eye care centers.
Orthopedics — Knee Evaluation Template
The Knee Evaluation Template is designed for orthopedic surgeons and sports medicine physicians evaluating patients with knee complaints. This template documents comprehensive knee assessment including ligament stability testing, meniscal evaluation, patellofemoral assessment, and imaging interpretation. Supports appropriate billing for E/M services and includes sections for mechanism of injury, functional limitations, detailed physical examination with special tests, and treatment planning for ACL/PCL/meniscal/arthritic conditions. Ideal for orthopedic practices and sports medicine clinics.
Orthopedics — New Patient Consultation Template
The Orthopedics New Patient Consultation Template is designed for orthopedic surgeons seeing patients referred for musculoskeletal evaluation. This comprehensive template documents the initial orthopedic assessment including detailed history, mechanism of injury, functional status, physical examination, imaging review, and treatment planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for pain assessment, functional limitations, neurovascular status, and conservative vs surgical treatment options. Ideal for orthopedic practices, sports medicine clinics, and spine centers.
Orthopedics — Postoperative Follow-Up Template
The Postoperative Follow-Up Template is designed for orthopedic surgeons evaluating patients after surgical procedures. This template documents interval recovery, wound assessment, rehabilitation progress, imaging review, and return-to-activity planning. Supports appropriate billing for postoperative visits and includes sections for pain management, complication screening, functional milestones, physical therapy progress, and work/sport clearance. Ideal for orthopedic practices managing postoperative care across all subspecialties.
Orthopedics — Shoulder Evaluation Template
The Shoulder Evaluation Template is designed for orthopedic surgeons and sports medicine physicians evaluating patients with shoulder complaints. This template documents comprehensive shoulder assessment including rotator cuff evaluation, instability testing, labral assessment, and imaging interpretation. Supports appropriate billing for E/M services and includes sections for mechanism of injury, functional limitations, detailed physical examination with special tests, and treatment planning for rotator cuff, instability, and arthritic conditions. Ideal for orthopedic practices, sports medicine clinics, and shoulder specialty centers.
Orthopedics — Spine Evaluation Template
The Spine Evaluation Template is designed for orthopedic spine surgeons and physiatrists evaluating patients with neck or back complaints. This template documents comprehensive spine assessment including neurological examination, radiculopathy evaluation, myelopathy screening, and imaging interpretation. Supports appropriate billing for E/M services and includes sections for pain characteristics, functional limitations, detailed neurological examination, red flag screening, and treatment planning for degenerative, traumatic, and stenotic conditions. Ideal for spine surgery practices, pain management clinics, and neurosurgery offices.
Pain Management — Follow-up Template
The Pain Management Follow-up Template is designed for pain specialists monitoring patients with chronic pain. This template documents treatment response, medication efficacy, opioid monitoring, and ongoing care planning. Supports appropriate billing for established patient visits and includes pain reassessment, functional status tracking, and compliance monitoring. Ideal for pain clinics managing patients on chronic opioid therapy or interventional treatment plans.
Pain Management — New Patient Consultation Template
The Pain Management New Patient Consultation Template is designed for pain specialists evaluating patients with chronic pain conditions. This comprehensive template documents pain characterization, functional assessment, prior treatment history, and multimodal treatment planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for pain scoring, opioid risk assessment, interventional planning, and medication management. Ideal for pain clinics and interventional pain practices.
Patient Encounter Note Template — Office Visit Documentation
The Patient Encounter Note Template is a streamlined documentation tool for physicians documenting office visits, clinic appointments, and outpatient encounters. This efficient template captures essential clinical information while supporting appropriate E/M coding (99202-99215) and maintaining documentation standards. Designed for busy practices, the template balances thoroughness with efficiency, including sections for patient presentation, focused history, targeted examination, clinical assessment, and actionable treatment plan. The format works for new patient evaluations, established patient visits, acute problems, and chronic disease management. Ideal for primary care offices, specialty clinics, urgent care centers, and any outpatient setting requiring structured encounter documentation.
Pediatrics — Newborn Examination Template
The Newborn Examination Template is designed for pediatricians and neonatologists performing initial and subsequent newborn examinations. This comprehensive template documents birth history, APGAR scores, physical examination findings, feeding assessment, newborn screening status, and discharge readiness evaluation. Supports appropriate billing for newborn care services and includes sections for maternal history, delivery details, systematic physical examination, risk assessments, and anticipatory guidance. Ideal for hospital nurseries, birthing centers, and neonatal units.
Pediatrics — Sick Visit Template
The Pediatric Sick Visit Template is designed for pediatricians evaluating children with acute illnesses. This template documents focused history, symptom assessment, physical examination, diagnostic workup, and treatment planning for common pediatric presentations including fever, respiratory infections, GI illness, and rashes. Supports appropriate billing for E/M services and includes age-specific vital sign interpretation, red flag screening, and return precautions. Ideal for pediatric primary care practices, urgent care centers, and family medicine offices seeing pediatric patients.
Pediatrics — Well-Child Visit Template
The Well-Child Visit Template is designed for pediatricians conducting routine health supervision visits. This comprehensive template documents growth and development assessment, age-appropriate screening, immunization administration, anticipatory guidance, and preventive care. Supports appropriate billing for preventive medicine services and includes sections for growth parameters, developmental milestones, safety screening, nutrition assessment, and age-specific anticipatory guidance. Ideal for pediatric primary care practices, family medicine offices, and community health centers serving children.
Progress Note Template — Daily Medical Documentation
The Progress Note Template is designed for physicians, nurse practitioners, and physician assistants documenting daily patient encounters in inpatient, outpatient, and long-term care settings. This versatile template captures interval changes, response to treatment, clinical status updates, and ongoing care plans. The format supports appropriate E/M billing (99212-99215 outpatient, 99231-99233 inpatient) while ensuring continuity of care across encounters. Key sections include overnight events and interval history, subjective patient status, focused objective findings with vital sign trends, assessment of each active problem with clinical reasoning, and updated plan with next steps. This template is adaptable for hospital progress notes, nursing facility rounds, outpatient follow-ups, and subspecialty monitoring visits. Ideal for hospitalists, primary care providers, specialists, and any clinician documenting ongoing patient care.
Pulmonology — New Patient Consultation Template
The Pulmonology New Patient Consultation Template is designed for pulmonologists evaluating patients with respiratory complaints. This comprehensive template documents respiratory symptoms, pulmonary function assessment, imaging review, and treatment planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for dyspnea evaluation, cough characterization, sleep symptoms, pulmonary function interpretation, and management of COPD, asthma, ILD, and pulmonary nodules. Ideal for general pulmonology practices, asthma/COPD clinics, and ILD centers.
Rheumatology — New Patient Consultation Template
The Rheumatology New Patient Consultation Template is designed for rheumatologists evaluating patients with musculoskeletal and autoimmune complaints. This comprehensive template documents joint examination, inflammatory markers, autoantibody interpretation, and management planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for articular assessment, extra-articular manifestations, serologic workup, and DMARD initiation. Ideal for general rheumatology practices, lupus clinics, and inflammatory arthritis centers.
SOAP Note Template — Universal Medical Documentation
The SOAP Note Template is the gold standard for medical documentation used by physicians, nurse practitioners, and physician assistants across all specialties. SOAP (Subjective, Objective, Assessment, Plan) provides a systematic framework for documenting patient encounters that supports clinical decision-making, care continuity, and appropriate billing. This universal template includes structured sections for subjective findings (chief complaint, HPI, ROS, PMH, medications, allergies), objective data (vital signs, physical examination, diagnostic results), clinical assessment with differential diagnosis, and detailed treatment plan. The SOAP format is recognized by all healthcare systems and supports E/M coding (99202-99215) while ensuring comprehensive documentation. Ideal for outpatient visits, inpatient rounds, urgent care encounters, specialty consultations, and telehealth appointments across all medical specialties.
Time-Based Billing Documentation Template
The Time-Based Billing Documentation Template helps physicians accurately document total time for E/M code selection based on time thresholds rather than medical decision making complexity. This guide covers the 2021 E/M guidelines allowing time-based billing for office visits, prolonged services add-on codes, care coordination time, and proper documentation format. Includes time thresholds for each CPT code level (99202-99215), what activities count toward total time, and template language for compliant documentation.
Urgent Care — General Visit Template
The Urgent Care General Visit Template is designed for urgent care providers evaluating patients with common acute complaints. This efficient template documents focused history, physical examination, point-of-care testing, and treatment for conditions like URI, UTI, lacerations, sprains, and minor injuries. Supports appropriate billing for E/M services (99201-99215) and includes streamlined sections for chief complaint, HPI, focused exam, assessment, and disposition. Ideal for urgent care centers, retail clinics, and walk-in facilities handling acute but non-emergent presentations.
Urology — BPH Follow-up Template
The BPH Follow-up Template is designed for urologists managing patients with benign prostatic hyperplasia. This template documents LUTS progression, medication efficacy, and surgical planning. Supports appropriate billing for established patient visits and includes IPSS scoring, post-void residual monitoring, and treatment optimization. Ideal for general urology practices and men's health clinics.
Urology — New Patient Consultation Template
The Urology New Patient Consultation Template is designed for urologists evaluating patients with genitourinary complaints. This comprehensive template documents urologic symptoms, prostate assessment, voiding function, and treatment planning. Supports appropriate billing for new patient consultations (99243-99245) and includes sections for LUTS evaluation, hematuria workup, stone disease, and oncologic assessment. Ideal for general urology practices, men's health clinics, and urologic oncology centers.
Administrative — Emotional Support Animal Letter Template
The Emotional Support Animal Letter Template is designed for psychiatrists, psychiatric nurse practitioners, and mental health providers writing letters to support patient requests for emotional support animals (ESAs) in housing or travel. This template provides the structured format required by housing providers and airlines while maintaining clinical appropriateness and avoiding fraudulent documentation. The template includes sections for patient demographics and diagnosis, clinical relationship and treatment history, functional limitations and how ESA addresses them, professional opinion on ESA necessity, and provider attestation. This template ensures appropriate ESA documentation, supports legitimate patient needs, maintains clinical integrity, and protects providers from inappropriate requests. The template emphasizes clinical necessity and avoids language that could be misused. Ideal for psychiatric practices, mental health providers, and practices receiving ESA letter requests from established patients.
Administrative — FMLA Medical Certification Template
The FMLA Medical Certification Template guides healthcare providers through completing the required documentation for employees requesting Family and Medical Leave Act (FMLA) leave from their employers. The Family Medical Leave Act requires medical certification from healthcare providers to support employee requests for unpaid, job-protected leave for serious health conditions, care of family members, or qualifying military family events. This template follows the Department of Labor's WH-380-E (Certification of Healthcare Provider for Employee's Serious Health Condition) and WH-380-F (Certification for Family Member's Serious Health Condition) forms, systematically collecting all required information including patient demographics, diagnosis information (with sufficient detail without HIPAA violations), medical facts supporting need for leave, probable duration of condition, treatment plan and frequency, whether condition requires ongoing treatment, assessment of patient's inability to perform work functions, and whether intermittent or reduced schedule leave is medically necessary. The template ensures compliance with federal FMLA regulations, protects patient privacy while providing necessary information, supports employee rights to medical leave, and streamlines the certification process for busy providers. Ideal for family medicine, internal medicine, psychiatry, and all specialties that treat conditions warranting medical leave, this template prevents incomplete forms that delay employee leave approval and reduces provider time spent on administrative paperwork.
Administrative — Insurance Appeal Letter Template
The Insurance Appeal Letter Template is an essential resource for physicians and healthcare providers writing appeal letters to contest insurance denials for medications, procedures, or services. This template provides the structured format and persuasive clinical language required to successfully appeal denials and obtain coverage for medically necessary treatments. The template includes sections for denial information including claim number and denial reason, detailed clinical rationale explaining why the denial was incorrect, additional clinical information not previously submitted, supporting clinical evidence and guidelines, expected outcomes and benefits of treatment, risks of not approving the appeal, and professional attestation. This template streamlines the appeal process, maximizes appeal success rates, supports revenue recovery, and protects provider time by standardizing documentation. The structured format is adaptable for medication appeals, procedure appeals, service appeals, and other types of insurance denials. Ideal for busy clinical practices, specialty care providers frequently dealing with denials, and administrative staff responsible for managing appeals.
Administrative — Medical Clearance Letter Template
The Medical Clearance Letter Template is designed for physicians and healthcare providers completing documentation to clear patients for specific activities, procedures, or participation in programs. This template provides the structured format required for various clearance scenarios and includes sections for patient demographics, medical assessment, clearance determination, restrictions or accommodations if needed, and provider attestation. This template streamlines the clearance documentation process, ensures clear communication, supports appropriate activity participation, and protects provider time by standardizing documentation. The structured format is adaptable for fitness for duty, activity clearance, procedure clearance, and other clearance scenarios. Ideal for primary care practices, occupational medicine practices, and practices frequently completing clearance documentation.
Administrative — Medical Necessity Letter Template
The Medical Necessity Letter Template is an essential resource for physicians and healthcare providers writing letters of medical necessity (LMN) to support insurance coverage for medications, durable medical equipment (DME), procedures, or services. This template provides the structured format and clinical language required by insurance companies to justify medical necessity for treatments that may require additional documentation beyond standard prior authorization. The template includes patient demographic and clinical information, detailed clinical rationale explaining why the requested item or service is medically necessary, documentation of functional limitations and impact on daily activities, supporting clinical evidence and guidelines, expected outcomes and benefits, risks of not providing the service, and professional attestation. This template streamlines the LMN process, ensures inclusion of all required elements to maximize approval rates, supports compliance with insurer requirements, and protects provider time by standardizing documentation. The structured format is adaptable for DME requests (wheelchairs, CPAP machines, home health equipment), medication coverage, procedure authorizations, and other services requiring medical necessity justification. Ideal for busy clinical practices, specialty care providers frequently dealing with insurance requirements, and administrative staff responsible for completing medical necessity documentation.
Administrative — Prior Authorization Template
The Prior Authorization Letter Template is an essential resource for physicians, nurse practitioners, and administrative staff navigating the insurance prior authorization process for medications, procedures, and services. This comprehensive template provides the structured format and medical necessity language required by insurance companies to approve coverage for treatments that require pre-authorization. The template includes patient demographic and insurance information, healthcare provider credentials, specific service or medication requesting authorization, relevant ICD-10 diagnosis codes with clinical justification, detailed clinical rationale for medical necessity, documentation of previous treatments tried (step therapy requirements), supporting clinical evidence and guidelines, expected outcomes and risks of not providing treatment, and professional attestation language. This template streamlines the often time-consuming PA process, ensures inclusion of all required elements to minimize denials and delays, supports compliance with insurer requirements, and protects provider time by standardizing documentation. The structured format is adaptable for medication prior authorizations (expensive or non-formulary drugs), procedure authorizations (surgical procedures, imaging, diagnostic tests), durable medical equipment (DME), specialty referrals, and other services requiring pre-approval. Ideal for busy clinical practices, specialty care providers frequently dealing with PAs, and administrative staff responsible for completing authorization requests.
Administrative — Medical Referral Letter Template
The Medical Referral Letter Template is designed for primary care providers and specialists writing referral letters to other healthcare providers for consultation, specialized care, or procedures. This template provides a structured format for communicating patient information, clinical history, reason for referral, specific questions or goals for the consultation, and relevant clinical data. The template ensures complete information transfer between providers, facilitates timely specialist evaluation, supports care coordination, and improves patient outcomes through effective provider communication. Key sections include patient demographics and insurance information, referring provider information, reason for referral with clinical context, relevant medical history and current medications, diagnostic workup completed and results, specific questions or goals for the consultation, urgency of referral, and patient instructions. This template streamlines the referral process, reduces communication gaps between providers, and ensures specialists receive complete clinical information for efficient evaluation. Ideal for primary care practices making specialty referrals, specialists referring to other specialists, and practices managing complex patients requiring multiple provider coordination.
Administrative — Return to Work Letter Template
The Return to Work Letter Template is designed for physicians and healthcare providers completing documentation to clear employees to return to work after illness or injury. This template provides the structured format required by employers to evaluate fitness for duty and includes sections for patient demographics and employment information, medical diagnosis and current status, work restrictions or accommodations if needed, full clearance determination, expected duration of restrictions, and provider attestation. This template streamlines the return-to-work documentation process, ensures clear communication with employers, supports appropriate workplace accommodations, and protects provider time by standardizing documentation. The structured format is adaptable for various medical conditions and return-to-work scenarios. Ideal for primary care practices, occupational medicine practices, and practices frequently completing return-to-work documentation.
Administrative — School Excuse Note Template
The School Excuse Note Template is designed for physicians and healthcare providers completing documentation to excuse student absences from school for medical reasons. This template provides a simple, standardized format for school excuse notes while maintaining appropriate medical documentation. The template includes sections for student and school information, dates of absence, reason for absence, and provider attestation. This template streamlines the school excuse process, ensures clear communication with schools, supports student attendance policies, and protects provider time by standardizing documentation. The structured format is adaptable for various medical conditions causing school absence. Ideal for pediatric practices, family medicine practices, and practices frequently completing school excuse notes.
Administrative — Short-term Disability Letter Template
The Short-term Disability Letter Template is designed for physicians and healthcare providers completing documentation to support employee requests for short-term disability benefits. This template provides the structured format required by disability insurance companies to evaluate claims and includes sections for patient demographics and employment information, medical diagnosis with ICD-10 codes, clinical course and current status, functional limitations preventing work, expected duration of disability, treatment plan, and provider attestation. This template streamlines the disability documentation process, ensures inclusion of all required elements, supports timely claim processing, and protects provider time by standardizing documentation. The structured format is adaptable for various medical conditions causing temporary work disability. Ideal for primary care practices, occupational medicine practices, and practices frequently completing disability documentation.
Administrative — Work/School Excuse Note Template
The Work/School Excuse Note Template is designed for physicians and healthcare providers completing simple documentation to excuse patient absences from work or school for medical reasons. This template provides a concise, standardized format for work and school excuse notes while maintaining appropriate medical documentation. The template includes sections for patient and employer/school information, dates of absence, medical reason for absence, return date, and any activity restrictions if applicable. This template streamlines the excuse note process, ensures clear communication with employers and schools, supports attendance policies, and protects provider time by standardizing documentation. The structured format is adaptable for various medical conditions causing temporary absence. Ideal for primary care practices, pediatric practices, and practices frequently completing work and school excuse notes.
Internal Medicine — Chronic Care Management Note Template
The Chronic Care Management Note Template is designed for primary care providers and internists documenting non-face-to-face care management services for patients with multiple chronic conditions. This template supports Medicare CCM billing (CPT 99490, 99487, 99489) and documents care coordination activities, medication management, patient communication, and care plan updates. The template includes sections for care management activities performed, medication reconciliation and management, patient communication and education, care coordination with specialists, preventive care gaps addressed, care plan updates, time spent on care management, and documentation of 20+ minutes of non-face-to-face time. This template ensures appropriate CCM billing, supports value-based care delivery, facilitates care coordination, and improves chronic disease outcomes through systematic care management. Ideal for primary care practices billing for Medicare CCM, practices managing high volumes of chronic disease patients, and practices participating in value-based care programs.
Internal Medicine — Complex Patient Visit Template
The Complex Patient Visit Template is designed for internists and primary care providers managing patients with multiple active medical problems requiring comprehensive evaluation and coordination. This template supports appropriate billing for complex visits (CPT 99214-99215) and documents multiple problems, extensive history, comprehensive examination, and complex medical decision-making. The template includes sections for problem list with all active conditions, detailed history for each significant problem, comprehensive review of systems, complete physical examination, review of multiple test results, assessment of each problem with clinical reasoning, treatment plan addressing each problem, care coordination needs, and follow-up planning. This template ensures thorough documentation of complex patients, supports appropriate billing for complexity, facilitates care coordination, and improves patient outcomes through systematic management. Ideal for internal medicine practices, primary care practices managing complex patients, and practices participating in value-based care programs.
Internal Medicine — New Patient Consultation Template
The New Patient Consultation Template is designed for internists and internal medicine specialists conducting initial consultations for new patients. This comprehensive template documents complete medical history, physical examination, diagnostic assessment, and treatment recommendations. The template supports appropriate billing for consultation visits (CPT 99241-99245) and includes sections for reason for consultation and referring provider, comprehensive medical history including all chronic conditions, detailed review of systems, complete physical examination, review of outside records and test results, diagnostic assessment with differential diagnosis, treatment recommendations, coordination with referring provider, and follow-up planning. This template ensures thorough consultation documentation, supports care coordination, facilitates appropriate treatment planning, and maintains documentation standards for specialty consultations. Ideal for internal medicine practices, specialty internal medicine practices, and practices providing consultation services.
Internal Medicine — Geriatric Assessment Template
The Geriatric Assessment Template is designed for internists, geriatricians, and primary care providers conducting comprehensive evaluations for elderly patients (typically ages 65+). This template documents the multidimensional assessment including functional status, cognitive assessment, fall risk, medication review, social support, and advance care planning. The template supports appropriate billing for comprehensive geriatric assessments and includes sections for functional assessment including ADLs and IADLs, cognitive screening using standardized tools, fall risk assessment, medication review including polypharmacy assessment, social support and living situation, advance care planning discussion, physical examination including geriatric-focused assessment, assessment of geriatric syndromes, treatment recommendations, and care coordination needs. This template ensures comprehensive geriatric care, supports functional independence, identifies geriatric syndromes, and improves quality of life for elderly patients. Ideal for geriatric practices, internal medicine practices managing elderly patients, and practices providing comprehensive geriatric assessments.
Internal Medicine — Hospital Admission H&P Template
The Hospital Admission History and Physical (H&P) Template is a comprehensive documentation tool for hospitalists, internal medicine physicians, and medical residents admitting patients to the hospital. This template meets Joint Commission and CMS requirements for complete admission documentation within 24 hours of inpatient admission, systematically capturing all required elements for medical decision-making and care planning. The template includes structured sections for chief complaint and reason for admission, detailed history of present illness with pertinent emergency department course, complete past medical and surgical history, medications reconciliation, allergies, family and social history with relevant risk factors, comprehensive review of systems, thorough physical examination by body system, review of admission laboratories and imaging, assessment with problem list and ICD-10 codes, and detailed admission orders and treatment plan for each active problem. This standardized format ensures regulatory compliance, supports accurate DRG assignment and billing, facilitates care coordination among hospital teams, provides medico-legal protection through thorough documentation, and establishes baseline status for tracking clinical progress. Ideal for academic medical centers, community hospitals, hospitalist programs, and teaching services, this template supports quality inpatient care and reduces documentation burden for admitting providers.
Internal Medicine — Hospital Discharge Summary Template
The Hospital Discharge Summary Template is designed for hospitalists, internal medicine physicians, and medical residents completing discharge documentation for patients leaving the hospital. This comprehensive template meets CMS and Joint Commission requirements for discharge summaries, systematically documenting the admission course, hospital stay events, final diagnoses, discharge medications, follow-up instructions, and care transitions. The template ensures continuity of care by providing primary care providers and specialists with complete information about the hospitalization, supports accurate billing and coding, facilitates care transitions, and reduces readmission risk through clear discharge planning. Key sections include admission and discharge dates, admitting and discharge diagnoses with ICD-10 codes, brief hospital course with significant events and procedures, final assessment and problem list, discharge medications with dosages and instructions, discharge instructions including activity restrictions and diet, follow-up appointments scheduled, pending test results and who will follow up, patient education provided, and contact information for questions. This template supports quality care transitions and reduces communication gaps between hospital and outpatient providers. Ideal for hospitalist programs, internal medicine services, academic medical centers, and community hospitals ensuring quality discharge documentation.
Internal Medicine — Hospitalist Progress Note Template
The Hospitalist Progress Note Template is designed for hospitalists and internal medicine physicians documenting daily inpatient progress notes. This template efficiently documents the hospital course, daily assessment, treatment plan adjustments, and discharge planning while maintaining compliance with documentation requirements. The template supports appropriate billing for hospital visits (CPT 99231-99233) and includes sections for overnight events and changes, subjective assessment from patient and nursing, focused physical examination, review of laboratory and imaging results, assessment of each active problem with clinical reasoning, updated treatment plan for each problem, discharge planning updates, and plan for next 24 hours. This template ensures thorough daily documentation, supports care coordination, facilitates discharge planning, and maintains documentation efficiency for high-volume hospitalist practices. Ideal for hospitalist programs, internal medicine services, academic medical centers, and community hospitals managing daily inpatient documentation.
Internal Medicine — Post-Hospital Follow-up Template
The Post-Hospital Follow-up Template is designed for primary care providers and internists conducting follow-up visits within 7-14 days after hospital discharge. This template supports Medicare Transitional Care Management (TCM) billing requirements and ensures comprehensive documentation of post-discharge recovery, medication reconciliation, care coordination, and readmission prevention. The template includes sections for hospitalization summary and discharge diagnoses, post-discharge recovery including symptoms and functional status, medication reconciliation with comparison to pre-admission medications, follow-up on pending test results, specialist follow-up status, care coordination needs, assessment of recovery and complications, treatment plan adjustments, patient education on warning signs and when to seek care, and scheduling of additional follow-up if needed. This template ensures quality care transitions, supports TCM billing, reduces readmission risk, and improves patient outcomes through systematic post-discharge care. Ideal for primary care practices, internal medicine practices, and practices managing high volumes of post-discharge patients.
OB/GYN — Annual GYN Exam Template
The Annual GYN Exam Template is designed for obstetricians, gynecologists, and primary care providers conducting routine well-woman visits including pelvic examination, breast examination, cancer screening, and preventive care counseling. This comprehensive template documents all elements of the annual gynecologic examination including menstrual history, sexual history, contraception review, cancer screening status, physical examination findings, and preventive care recommendations. The template supports appropriate billing for preventive visits (CPT 99395-99397 for established patients) and includes sections for menstrual history and cycle characteristics, sexual history and contraception, cancer screening status including Pap smear, HPV testing, mammography, and colonoscopy, family history of gynecologic cancers, physical examination including breast exam and pelvic exam, assessment of gynecologic health, screening test orders, patient education on preventive care and health maintenance, and scheduling of next annual exam. This template ensures comprehensive well-woman care addressing reproductive health, cancer prevention, and overall health maintenance. Ideal for OB/GYN practices, primary care practices providing gynecologic care, and women's health clinics.
OB/GYN — Contraception Counseling Template
The Contraception Counseling Template is designed for obstetricians, gynecologists, and primary care providers conducting visits focused on contraceptive counseling and initiation. This template documents patient preferences, medical history relevant to contraception, risk assessment for different methods, method selection, patient education, and follow-up planning. The template supports appropriate billing for contraceptive counseling visits and includes sections for patient's reproductive goals and preferences, medical history including contraindications to specific methods, previous contraceptive experience, physical examination if indicated, assessment of appropriate contraceptive options, method selection with shared decision-making, patient education on selected method use, follow-up planning, and STI screening if indicated. This template ensures comprehensive contraceptive counseling, supports patient-centered method selection, facilitates appropriate method initiation, and improves contraceptive adherence through thorough education. Ideal for OB/GYN practices, family medicine practices providing gynecologic care, women's health clinics, and practices managing contraceptive services.
OB/GYN — Postpartum Visit Template
The Postpartum Visit Template is designed for obstetricians, family medicine providers, and midwives conducting the standard 6-week postpartum visit following delivery. This comprehensive template documents maternal recovery, physical examination including pelvic exam, contraception counseling, mental health screening, breastfeeding support, and return to activity guidance. The template supports appropriate billing for postpartum visits (CPT 59430) and includes sections for delivery information and complications, postpartum recovery including bleeding, pain, and healing, breastfeeding or formula feeding status, mental health screening including postpartum depression assessment, physical examination including pelvic exam and healing assessment, contraception counseling and initiation, return to activity and exercise guidance, and ongoing care planning. This template ensures comprehensive postpartum care addressing both physical recovery and emotional well-being. Ideal for OB/GYN practices, family medicine practices providing obstetric care, midwifery practices, and practices managing postpartum complications.
OB/GYN — Prenatal Initial Visit Template
The Initial Prenatal Visit Template is designed for obstetricians, family medicine providers, and midwives conducting the first comprehensive prenatal visit for pregnant patients. This comprehensive template documents obstetric history, medical and surgical history, risk assessment, physical examination, baseline laboratory testing, and initial prenatal care planning. The template supports appropriate billing for initial prenatal visits (CPT 59400) and includes sections for pregnancy confirmation and dating, comprehensive obstetric history including gravidity, parity, and previous pregnancy outcomes, medical and surgical history relevant to pregnancy, family history including genetic conditions, social history including substance use and support systems, physical examination including baseline assessment, baseline prenatal laboratory testing, risk assessment for pregnancy complications, initial prenatal care plan including ultrasound scheduling, genetic screening options, and patient education on nutrition, activity, medications, and warning signs. This template ensures thorough initial prenatal evaluation, identifies high-risk pregnancies early, establishes foundation for ongoing prenatal care, and improves pregnancy outcomes through comprehensive assessment. Ideal for OB/GYN practices, family medicine practices providing obstetric care, midwifery practices, and practices managing initial prenatal visits.
OB/GYN — Routine Prenatal Visit Template
The Routine Prenatal Visit Template is designed for obstetricians, family medicine providers, and midwives conducting standard prenatal care visits throughout pregnancy. This template documents the essential elements of routine prenatal visits including interval history, fetal assessment, maternal health monitoring, and anticipatory guidance. The template supports appropriate billing for prenatal visits (CPT 59400 for initial, 59425-59426 for subsequent visits) and includes sections for gestational age and estimated due date, interval history including fetal movement, maternal symptoms, and concerns, vital signs including blood pressure and weight, fundal height measurement, fetal heart rate assessment, review of prenatal labs and screening results, assessment of pregnancy status, patient education on nutrition, activity, warning signs, and preparation for delivery, and scheduling of next appointment. This template ensures comprehensive prenatal care documentation while maintaining efficiency for high-volume obstetric practices. Ideal for OB/GYN practices, family medicine practices providing obstetric care, midwifery practices, and community health centers offering prenatal services.
Primary Care — Acute Sick Visit Template
The Acute Sick Visit Template is designed for primary care providers managing same-day or urgent care visits for acute complaints such as upper respiratory infections, urinary tract infections, acute injuries, and other non-emergent conditions. This focused template efficiently documents the chief complaint, focused history of present illness, targeted review of systems, focused physical examination, assessment, and treatment plan for acute conditions. The template supports appropriate billing for acute care visits (CPT 99212-99215 for established patients, 99202-99205 for new patients) while ensuring thorough documentation of medical decision-making. Key sections include symptom onset and duration, associated symptoms, severity assessment, relevant past medical history affecting treatment, focused physical examination findings, diagnostic considerations, treatment plan with medications or procedures, patient education on symptom management and warning signs, and follow-up instructions. This template streamlines documentation for high-volume acute care visits while maintaining quality and compliance. Ideal for primary care clinics, urgent care centers, walk-in clinics, and family medicine practices managing acute patient complaints.
Primary Care — Annual Physical Exam Template
The Adult Annual Physical Exam Template is designed for family medicine and internal medicine providers conducting preventive care visits for adult patients. This comprehensive template follows evidence-based screening guidelines from USPSTF and includes all required elements for Medicare Annual Wellness Visits and commercial insurance preventive care codes (99385-99387 for new patients, 99395-99397 for established patients). The template systematically documents health risk assessment, review of systems, age-appropriate screening tests, immunization status, lifestyle counseling, and preventive care recommendations. Sections include comprehensive health history review, complete physical examination, assessment of cardiovascular risk factors, cancer screening status, mental health screening, fall risk assessment for elderly patients, advance directive discussion, and personalized prevention plan. This template ensures thorough documentation that maximizes quality metrics, supports value-based care initiatives, and provides continuity for annual health maintenance tracking. Ideal for primary care practices focused on preventive medicine and population health management.
Primary Care — Asthma Management Visit Template
The Asthma Management Visit Template is designed for primary care providers, pediatricians, and pulmonologists managing patients with asthma. This focused template documents asthma control assessment, medication management, environmental trigger identification, action plan review, and patient education. The template supports appropriate billing for chronic disease management visits and includes sections for asthma control assessment using standardized tools, symptom frequency and severity, medication adherence and technique, environmental triggers and exposure, physical examination including respiratory assessment, peak flow measurements if applicable, assessment of asthma control level, medication adjustments including controller and rescue medications, asthma action plan review and updates, patient education on trigger avoidance and medication use, and follow-up planning. This template ensures comprehensive asthma care, supports asthma control goals, facilitates medication optimization, and improves patient outcomes through systematic management. Ideal for primary care practices managing asthma, pediatric practices, pulmonology practices, and practices participating in asthma quality improvement programs.
Primary Care — Chronic Disease Management Visit Template
The Chronic Disease Management Visit Template is designed for primary care providers conducting structured visits for patients with chronic conditions such as diabetes, hypertension, heart disease, COPD, and other long-term health conditions. This template supports Medicare Chronic Care Management (CCM) billing requirements and ensures comprehensive documentation of disease status, medication management, self-management support, and care coordination. The template includes sections for chronic condition review with current status and control, medication reconciliation and adherence assessment, symptom monitoring, self-management goal setting and support, preventive care gaps identification, care coordination with specialists, patient education on disease management, and follow-up planning. This template facilitates value-based care delivery, supports quality metric reporting, ensures appropriate CCM billing, and improves chronic disease outcomes through systematic care management. Ideal for primary care practices participating in value-based care programs, practices managing high volumes of chronic disease patients, and practices billing for Medicare CCM services.
Primary Care — Depression Follow-up Template
The Depression Follow-up Visit Template is designed for primary care providers managing depression in the primary care setting. This focused template documents symptom response using standardized scales, medication effectiveness, side effects, functional improvement, and treatment plan adjustments. The template supports appropriate billing for medication management visits and includes sections for interval history since last visit, depression symptom assessment using PHQ-9 or other standardized tools, medication review with adherence and response, side effect monitoring, functional status assessment, suicide risk screening, treatment plan adjustments including medication changes, psychotherapy referral if indicated, patient education on depression and treatment, and follow-up scheduling. This template ensures comprehensive depression care in primary care, supports medication optimization, facilitates systematic symptom tracking, and improves patient outcomes through structured follow-up. Ideal for primary care practices managing depression, family medicine practices, and integrated behavioral health programs.
Primary Care — Diabetes Management Visit Template
The Diabetes Management Visit Template is specifically designed for primary care physicians, endocrinologists, and nurse practitioners managing patients with Type 1 or Type 2 diabetes mellitus. This focused template ensures comprehensive documentation of diabetes control, complications screening, medication management, and patient education required for quality reporting measures like HEDIS and MIPS. The template systematically addresses glycemic control metrics, diabetes-related complications assessment, cardiovascular risk reduction, medication optimization, and lifestyle modification counseling. Key sections include blood glucose monitoring review, A1C trends, hypoglycemia history, diabetic complication screening (retinopathy, nephropathy, neuropathy, cardiovascular disease), foot examination, medication adherence assessment, nutrition counseling documentation, and shared decision-making for treatment intensification. This template supports value-based care quality metrics including A1C control, blood pressure management, statin therapy, ACE inhibitor use, annual eye exams, and diabetic foot care. Ideal for chronic care management programs, endocrinology practices, and primary care providers managing the growing diabetic patient population.
Primary Care — Follow-up Visit Template
The Follow-up Visit Template is designed for primary care providers conducting routine return visits for established patients. This streamlined template efficiently documents interval history since last visit, medication adherence and response, symptom changes, focused physical examination, assessment of condition status, and treatment plan adjustments. The template supports appropriate billing for established patient visits (CPT 99212-99215) while maintaining documentation efficiency for high-volume follow-up appointments. Key sections include interval history with changes since last visit, medication review with adherence assessment and side effects, symptom tracking and response to treatment, focused physical examination relevant to ongoing conditions, assessment of condition status (improved, stable, worsened), treatment plan adjustments including medication changes, laboratory or imaging follow-up, patient education reinforcement, and scheduling of next appointment. This template balances thoroughness with efficiency, ensuring quality documentation without excessive time burden. Ideal for primary care practices managing chronic conditions, routine follow-ups, medication monitoring visits, and post-procedure follow-up appointments.
Primary Care — Hypertension Follow-up Template
The Hypertension Follow-up Visit Template is designed for primary care providers, internists, and cardiologists managing patients with hypertension. This focused template documents blood pressure control, medication adherence, lifestyle factors, and treatment optimization. The template supports appropriate billing for chronic disease management visits and includes sections for blood pressure trends including home monitoring data, medication review with adherence assessment and side effects, lifestyle factors including diet, exercise, sodium intake, and alcohol consumption, physical examination including blood pressure measurement and cardiovascular assessment, assessment of hypertension control status, medication adjustments including dose changes or additions, patient education on hypertension management and lifestyle modifications, and follow-up planning. This template ensures comprehensive hypertension care, supports blood pressure control goals, facilitates medication optimization, and improves patient outcomes through systematic management. Ideal for primary care practices managing hypertension, cardiology practices, and practices participating in hypertension quality improvement programs.
Primary Care — New Patient Visit Template
The Adult New Patient Visit Template is a comprehensive documentation tool designed for family medicine physicians, internists, and primary care providers conducting initial patient evaluations. This template provides a structured approach to documenting the patient's complete medical history, comprehensive physical examination, problem list, assessment, and treatment plan. Ideal for establishing care with new patients, this template ensures thorough documentation that meets billing requirements for 99204-99205 CPT codes while capturing all essential clinical information. The template includes sections for chief complaint, history of present illness, past medical history, surgical history, family history, social history, medications, allergies, review of systems, physical examination by body system, assessment with ICD-10 diagnostic codes, and detailed treatment plans. This standardized format improves documentation efficiency, ensures regulatory compliance, and facilitates continuity of care for primary care practices, internal medicine clinics, and multi-specialty groups.
Primary Care — Newborn Visit Template
The Newborn Visit Template is designed for pediatricians and family medicine providers conducting the initial newborn examination and establishing care for infants. This comprehensive template documents the complete newborn evaluation including birth history, feeding assessment, physical examination, developmental assessment, screening test results, and anticipatory guidance. The template supports appropriate billing for newborn visits (CPT 99460-99462) and includes sections for birth history including delivery type and complications, feeding history including breastfeeding or formula feeding status, elimination patterns, physical examination including comprehensive newborn assessment, weight and growth parameters, screening test results including newborn screen and hearing screen, assessment of newborn health and development, anticipatory guidance for parents, and follow-up scheduling. This template ensures thorough newborn care, identifies health concerns early, supports parent education, and establishes foundation for ongoing pediatric care. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing newborns in the first weeks of life.
Primary Care — Pre-operative Clearance Template
The Pre-operative Clearance Template is designed for primary care providers and internists conducting medical clearance evaluations for patients scheduled for surgery. This template documents the comprehensive assessment required to determine surgical risk and optimize patients for procedures including cardiovascular risk assessment, medication management, optimization of chronic conditions, and clearance recommendations. The template supports appropriate billing for pre-operative consultations (CPT 99241-99245) and includes sections for planned surgery and surgeon information, patient's medical history and chronic conditions, current medications requiring perioperative management, cardiovascular risk assessment, functional capacity evaluation, physical examination findings, laboratory and diagnostic test results, risk stratification, recommendations for perioperative management, and clearance determination. This template ensures thorough pre-operative evaluation, identifies modifiable risk factors, supports appropriate surgical planning, and protects both patients and providers through comprehensive documentation. Ideal for primary care practices, internal medicine practices, and practices providing pre-operative clearance services.
Primary Care — School-Age Checkup Template
The School-Age Checkup Template is designed for pediatricians and family medicine providers conducting annual well-child visits for school-age children (ages 5-18). This comprehensive template documents growth assessment, developmental milestones, school performance, behavioral assessment, physical examination, immunization status, screening tests, and anticipatory guidance. The template supports appropriate billing for well-child visits (CPT 99391-99395) and includes sections for growth parameters and BMI percentile, developmental milestones appropriate for age, school performance and academic concerns, behavioral and social development, physical examination including comprehensive assessment, immunization status and catch-up needs, screening tests including vision, hearing, and laboratory tests, assessment of child health and development, safety assessment including injury prevention, anticipatory guidance for parents and children, and scheduling of next well-child visit. This template ensures thorough well-child care for school-age children, tracks growth and development, supports school readiness and performance, and provides essential health and safety guidance. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing routine well-child visits for school-age children.
Primary Care — Sports Physical Template
The Sports Physical Template is designed for primary care providers, pediatricians, and family medicine physicians conducting pre-participation physical examinations (PPE) for athletes. This template documents the comprehensive evaluation required for sports clearance including medical history, cardiovascular screening, musculoskeletal assessment, and clearance determination. The template supports appropriate billing for sports physicals (CPT 97169-97171) and includes sections for sport and level of participation, medical history including cardiac risk factors and previous injuries, family history of sudden cardiac death or other relevant conditions, physical examination including cardiovascular, pulmonary, musculoskeletal, and neurological systems, clearance determination with any restrictions or recommendations, and follow-up requirements. This template ensures thorough pre-participation evaluation, identifies athletes at risk, supports appropriate clearance decisions, and protects both athletes and providers through comprehensive documentation. Ideal for primary care practices, pediatric practices, sports medicine clinics, and school-based health centers conducting sports physicals.
Primary Care — Telehealth Visit Template
The Telehealth Visit Template is designed for primary care providers conducting virtual visits via video or telephone. This template addresses the unique documentation requirements for telemedicine encounters including technology platform used, patient location, verification of patient identity, assessment of appropriateness for telehealth, focused history and examination adapted for remote assessment, and treatment plan with appropriate follow-up. The template ensures compliance with telehealth billing requirements (CPT 99211-99215 with modifier 95 or GQ) and documents the unique aspects of remote care delivery. Key sections include visit type (video vs. telephone), patient location and technology verification, focused history adapted for remote assessment, visual examination findings when possible via video, assessment of appropriateness for telehealth vs. in-person evaluation, treatment plan with prescriptions sent electronically, patient education on self-monitoring and warning signs, and clear instructions for when in-person evaluation is needed. This template supports the growing demand for telehealth services while maintaining quality documentation standards. Ideal for primary care practices offering telehealth options, rural practices serving remote patients, and practices managing patients with mobility limitations or transportation barriers.
Primary Care — Upper Respiratory Infection Template
The Upper Respiratory Infection Template is designed for primary care providers evaluating and treating patients with acute upper respiratory symptoms including cough, congestion, sore throat, and sinus symptoms. This focused template documents symptom assessment, physical examination findings, determination of viral vs. bacterial etiology, appropriate treatment including symptomatic care and antibiotic stewardship, and patient education on expected course and warning signs. The template supports appropriate billing for acute care visits and includes sections for symptom onset and duration, associated symptoms including fever and systemic symptoms, physical examination including HEENT and respiratory assessment, assessment of red flags requiring further evaluation, determination of viral vs. bacterial etiology, treatment plan emphasizing symptomatic care and appropriate antibiotic use, patient education on expected course and self-care, and return precautions. This template ensures quality acute care, supports antibiotic stewardship, reduces inappropriate antibiotic prescribing, and improves patient outcomes through appropriate management. Ideal for primary care practices, urgent care centers, and practices managing high volumes of acute respiratory complaints.
Primary Care — 1-Year Well Child Visit Template
The 1-Year Well Child Visit Template is designed for pediatricians and family medicine providers conducting the standard 12-month well-child checkup. This comprehensive template documents growth assessment, developmental milestones including motor skills and language development, feeding transition to table foods, safety assessment, immunization administration, and anticipatory guidance. The template supports appropriate billing for well-child visits (CPT 99391-99392) and includes sections for growth parameters and percentiles, developmental milestones assessment including walking, talking, and fine motor skills, feeding history including transition to table foods and weaning, elimination patterns, physical examination including comprehensive assessment, immunization administration including MMR and varicella, screening test results including lead and hemoglobin, assessment of toddler health and development, safety assessment including home safety and injury prevention, anticipatory guidance for parents, and scheduling of next well-child visit. This template ensures thorough well-child care, tracks important developmental transitions, supports immunization compliance, and provides essential safety and nutrition guidance. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing routine well-child visits.
Primary Care — 2-Month Well Child Visit Template
The 2-Month Well Child Visit Template is designed for pediatricians and family medicine providers conducting the standard 2-month well-child checkup. This template documents the comprehensive evaluation including growth assessment, developmental milestones, feeding status, immunization administration, and anticipatory guidance. The template supports appropriate billing for well-child visits (CPT 99391-99392) and includes sections for growth parameters and percentiles, developmental milestones assessment, feeding history including breastfeeding or formula feeding, elimination patterns, physical examination including comprehensive assessment, immunization administration and scheduling, screening test results, assessment of infant health and development, anticipatory guidance for parents, and scheduling of next well-child visit. This template ensures thorough well-child care, tracks growth and development, supports immunization compliance, and provides essential parent education. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing routine well-child visits.
Psychiatry — ADHD Assessment and Management Template
The ADHD Assessment and Management Template is designed for psychiatrists, psychiatric nurse practitioners, and primary care providers evaluating and managing patients with attention-deficit/hyperactivity disorder (ADHD). This comprehensive template documents the diagnostic evaluation process including symptom assessment across multiple settings, functional impairment evaluation, differential diagnosis considerations, treatment planning including medication management and behavioral interventions, and ongoing monitoring of treatment response and side effects. The template follows DSM-5 diagnostic criteria for ADHD and includes sections for symptom history across inattention, hyperactivity, and impulsivity domains, childhood onset documentation, functional impairment in academic, occupational, and social domains, collateral information from family, teachers, or employers, standardized rating scales (Vanderbilt, Conners, ASRS), physical examination including vital signs and growth parameters, cardiovascular risk assessment for stimulant medications, treatment plan with medication selection and dosing, behavioral interventions and accommodations, school or workplace accommodations, and follow-up monitoring. This template supports quality ADHD care, ensures thorough diagnostic documentation, facilitates medication management, and supports academic and occupational accommodations. Ideal for child and adolescent psychiatry practices, adult ADHD clinics, primary care practices managing ADHD, and integrated behavioral health programs.
Psychiatry — Adult Psychiatric Intake Template
The Adult Psychiatric Intake Template is designed for psychiatrists and psychiatric nurse practitioners conducting initial evaluations for adult patients (ages 18+). This comprehensive template documents psychiatric history, mental status examination, risk assessment, diagnostic formulation, and initial treatment planning. The template follows DSM-5 diagnostic criteria and includes sections for chief complaint and reason for referral, history of present illness with detailed symptom assessment, past psychiatric history including diagnoses and treatments, substance use history, medical history and medications, family psychiatric history, social and developmental history, complete mental status examination, suicide and violence risk assessment, diagnostic impressions with ICD-10 codes, initial treatment plan including medication and therapy recommendations, safety planning if indicated, and follow-up scheduling. This template ensures thorough psychiatric evaluation, supports accurate diagnosis, facilitates appropriate treatment planning, and establishes foundation for ongoing psychiatric care. Ideal for outpatient psychiatry clinics, private practice psychiatrists, community mental health centers, and integrated behavioral health programs.
Psychiatry — Child/Adolescent Psychiatric Intake Template
The Child/Adolescent Psychiatric Intake Template is designed for child and adolescent psychiatrists and psychiatric nurse practitioners conducting initial evaluations for patients under age 18. This comprehensive template documents developmental history, family history, school performance, psychiatric symptoms, mental status examination, risk assessment, and treatment planning. The template follows DSM-5 diagnostic criteria and includes sections for chief complaint and reason for referral, developmental history including milestones and delays, school performance and behavioral concerns, family psychiatric and medical history, social history including peer relationships and activities, psychiatric symptoms appropriate for age, collateral information from parents, teachers, or other sources, mental status examination adapted for age, suicide and self-harm risk assessment, diagnostic impressions with ICD-10 codes, initial treatment plan including family involvement, and follow-up scheduling. This template ensures thorough child/adolescent psychiatric evaluation, supports accurate diagnosis, facilitates appropriate treatment planning, and establishes foundation for ongoing psychiatric care. Ideal for child and adolescent psychiatry practices, pediatric mental health clinics, and practices managing psychiatric care for minors.
Psychiatry: Therapy and Medication Visit Template
The Combined Therapy and Medication Management Visit Template is designed for psychiatrists and psychiatric nurse practitioners providing both psychotherapy and medication management in a single visit. This template efficiently documents both therapeutic interventions and medication management while supporting appropriate billing for combined services (CPT 90834 or 90837 with medication management). The template includes sections for session focus and therapeutic interventions, patient response to therapy, medication review with adherence and response, side effect monitoring, symptom assessment, treatment plan adjustments for both therapy and medications, and follow-up planning. This template ensures comprehensive documentation of combined services, supports appropriate billing, maintains efficiency for providers offering integrated care, and improves patient outcomes through coordinated treatment. Ideal for psychiatric practices providing integrated care, practices managing patients requiring both therapy and medication, and practices optimizing visit efficiency.
Psychiatry — Comprehensive Psychiatric Evaluation Template
The Comprehensive Psychiatric Evaluation Template is an essential tool for psychiatrists, psychiatric nurse practitioners, and mental health professionals conducting initial diagnostic assessments. This detailed template provides systematic documentation of psychiatric history, mental status examination, risk assessment, diagnostic formulation, and treatment planning required for the first psychiatric encounter. The template follows DSM-5 diagnostic criteria and includes sections for chief complaint, history of present illness with detailed symptom assessment, past psychiatric history including previous diagnoses and treatments, substance use history, trauma history, complete mental status examination, suicide and violence risk assessment, diagnostic impressions with ICD-10 codes, initial treatment plan including psychotherapy modality and medication considerations, safety planning, and follow-up scheduling. This comprehensive structure supports quality psychiatric care, ensures thorough risk assessment documentation, meets billing requirements for psychiatric diagnostic evaluation (CPT 90791-90792), facilitates treatment continuity across providers, and establishes baseline functioning for outcome measurement. Ideal for outpatient psychiatry clinics, community mental health centers, hospital psychiatric consult services, and private practice mental health providers.
Psychiatry — Depression Follow-up Visit Template
The Depression Follow-up Visit Template is designed for psychiatrists, psychiatric nurse practitioners, and primary care providers conducting follow-up visits for patients with depression. This focused template documents symptom response, medication effectiveness, side effects, functional improvement, and treatment plan adjustments. The template supports appropriate billing for medication management visits and includes sections for interval history since last visit, depression symptom assessment using standardized scales when appropriate, medication review with adherence and response, side effect monitoring, functional status assessment, suicide risk reassessment, treatment plan adjustments including medication changes, psychotherapy referral if indicated, patient education on depression and treatment, and follow-up scheduling. This template ensures comprehensive depression care, supports medication optimization, facilitates systematic symptom tracking, and improves patient outcomes through structured follow-up. Ideal for psychiatric practices, primary care practices managing depression, integrated behavioral health programs, and practices providing medication management for depression.
Psychiatry — Medication Management Follow-up Template
The Medication Management Visit Template is designed for psychiatrists, psychiatric nurse practitioners, and physician assistants conducting follow-up visits focused on psychotropic medication optimization. This streamlined template efficiently documents medication response, side effect monitoring, mental status assessment, and treatment plan adjustments required for brief medication management appointments (CPT 99212-99214 with add-on psychiatric services). The template includes focused interval history since last visit, current medication review with adherence assessment, symptom tracking using standardized scales when appropriate, side effect inventory, abbreviated mental status exam, risk reassessment, medication adjustments with rationale, laboratory monitoring when indicated, and brief supportive interventions. This focused structure supports high-quality psychopharmacologic care while maintaining efficiency for typical 15-30 minute medication management appointments. The template facilitates systematic symptom tracking, ensures thorough side effect monitoring, documents medical necessity for medication changes, and supports quality metrics for medication safety and efficacy. Ideal for outpatient psychiatry practices, psychiatric clinics, community mental health centers conducting medication clinics, and integrated primary care behavioral health programs with prescribing providers.
Psychiatry — Substance Abuse Assessment Template
The Substance Abuse Assessment Template is designed for psychiatrists, addiction medicine specialists, and mental health providers conducting comprehensive evaluations for substance use disorders. This detailed template documents substance use history, patterns of use, consequences, withdrawal symptoms, treatment history, and treatment planning. The template follows DSM-5 diagnostic criteria for substance use disorders and includes sections for comprehensive substance use history including all substances used, patterns of use including frequency and quantity, route of administration, tolerance and withdrawal symptoms, functional impairment assessment, legal and social consequences, previous treatment attempts and outcomes, readiness for change assessment, physical examination findings, laboratory testing including drug screens, diagnostic formulation, treatment recommendations including level of care determination, and follow-up planning. This template ensures thorough substance use evaluation, supports accurate diagnosis, facilitates appropriate treatment planning, and improves patient outcomes through comprehensive assessment. Ideal for addiction medicine practices, psychiatric practices managing substance use, primary care practices with addiction services, and treatment centers conducting intake evaluations.
Psychiatry — Therapy Session Note Template
The Therapy Session Note Template is designed for mental health providers conducting psychotherapy sessions including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), psychodynamic therapy, supportive therapy, and other therapeutic modalities. This template efficiently documents session content, therapeutic interventions, patient progress, treatment goals, and treatment plan adjustments while maintaining appropriate detail for billing and clinical documentation. The template supports billing for psychotherapy services (CPT 90834, 90837, 90847 for family therapy, 90853 for group therapy) and includes sections for session type and modality, presenting concerns and session focus, therapeutic interventions used, patient response and engagement, progress toward treatment goals, homework assignments or between-session tasks, risk assessment updates, treatment plan modifications, and scheduling of next session. This template balances thorough clinical documentation with efficiency for high-volume therapy practices. Ideal for outpatient mental health clinics, private practice therapists, integrated behavioral health programs, and community mental health centers providing psychotherapy services.
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