Introduction to Clinical Notes: Templates

  • 4
  • Article
  • Updated 1 year ago
This article follows on from Introduction to Clinical Notes: Essentials.

In this article we will discuss the use of Clinical Notes Templates in order to bring consistency, structure and efficiency to your clinical note taking.

Clinical Notes Templates in Front Desk offer a high level of customisation and flexibility. Where necessary, users can create their own templates based on consulting/treatment workflows that incorporate:
  • Check boxes
  • Drop-down lists
  • Tables
  • Editable images
  • Customisable Body Charts

1. Creating a Template

To create a Clinical Notes Template select System > Clinical Notes Templates



Select Add to create a new Clinical Note Template. 

Note that you can add multiple templates to suit the needs of your practice and the services offered.


 
For the purpose of this article, select Standard template. Options are also available to create a Chart template (chart/image only). Old style template should no longer be used and is only available for backward compatibility with previous Front Desk clinical notes templates.



After selecting Standard template, the Front Desk Word Processor will open where you can start designing the layout of your template. The tools to create your template are located underneath the Font Format options as seen below. 


 
From left to right these elements are:
  • Text Form Field
  • Check Box Form Field
  • Drop-Down Form Field
  • Insert Table
  • Insert Text Box
  • Form Field Shading
  • Protect Form
Additionally, more options can be found under the Insert menu including Graphics, Page Numbers and Symbols. You can also add system data fields using the Standard Letter Tags found under the View menu.



We will be recreating the template below which aims to incorporate some of these Clinical Notes elements. 



2. Creating Tables, Labels and Standard Letter Tags

To create our Patient Information section (highlighted in light grey above) click the Insert Table button. In this case, we do not need to alter any of the default settings, so just select OK.



Let’s now create the required labels in the header of your template. Click in the upper left corner of your table, select the Bold icon and type in ‘Name:’.  Tab to the next cell and type ‘DOB:’ and continue the same for ‘Fee Cat:’ and ‘File No:’ in the correct areas of the table.



We will insert some Standard Letter Tags so that we can grab the information directly from the patient’s file. Select View > Standard Letter Tags to bring up the list on the right side of the screen. Put the cursor inside the relevant cell and double click on the relevant letter tag to insert into your template including FullName, DateOfBirth, FeeCategory and FileNo as below.



To add some additional formatting, highlight the table, select the Paragraph Background drop down menu and select light grey.



While the table is highlighted, select the Border button and then select no borders option.



3. Adding Form Fields to Templates

Click below the table and hit Enter on the keyboard to create a new line. Type the label ‘Injury Type:’. Then select the Drop-Down Form Field button to insert a blank drop-down list.



Double click the blank drop-down list to edit the selectable items in this list. Enter your list items and click Add>> to include and OK to save these changes.



Drop a line and then add the label ‘Pain Level:’, leave a few spaces and then press the Check Box Form Field button and then type the number ‘1’. Repeat with further check boxes and sequential numbers until you have completed your Pain Level scale.



To create the SOAP section, insert a new table using the steps outlined above that is 9 rows by 2 columns.



Highlight the entire top row, select Table > Merge Cells to create the header line.



Type in ‘SOAP Note’, centre your text, change the background colour to black and make the font colour white using the formatting options highlighted at the top of the next image.



Now drag out every second row to provide an area for a label and area to be able to write your notes as shown below.



We now want to make a space for 2 body charts. Select the first 4 rows in the right column and merge them together. Do the same for the bottom 4 rows to make room for your body charts.



Type in your typical headings for SOAP notes such as: Subjective, Objective, Assessment and Plan and fill the background with blue, remove the bolding and make the font colour white as previously shown using the text formatting tools.



Place the cursor in the space provided for your first body chart (top right box) and add 2 line spaces for some vertical space. Select Insert > Graphic from the menu and add your chosen body chart image. The sample body charts used have been included at the end of this article for your use if required. 



Finally, we need to create a text area in order to be able to add your notes under each SOAP heading. Do not be concerned with the small size of the text form field as it will expand as you type. Place the cursor into the empty box under the Subjective heading and insert a Text Form Field. Repeat for the cells under each of the subsequent headings.



4. Locking Templates

After adding these features to your clinical note template it is important that you prepare the template for use by locking the form. This changes the functionality of the template from design mode to user mode. This is done by clicking on the lock symbol in the form field toolbar. In user mode you can now interact with the form field objects such as the drop down list and check boxes.



5. Using Your Template

You can now exit the Front Desk Word Processor ensuring you select ‘Yes’ to save your changes. On the next window you can give your template a description and select the appropriate Note Type from the drop down box.



The next step is to use your template on the Patient File. Open a test Patient File and select the Clinical Notes tab. Create a New Note and select the Template button.

 

The final step is to select the Clinical Note Template created above and to start recording your notes.

You can download the body charts used in this template at the links below:
AP Body Chart
Lateral Body Chart
Photo of Timothy

Timothy, Business Care Manager

  • 761 Posts
  • 220 Reply Likes

Posted 3 years ago

  • 4
Photo of david donkin

david donkin

  • 95 Posts
  • 33 Reply Likes
Thanks for the step by step, it is appreciated.
Given that this is a basic SOAP form that would serve as a base for people to fiddle with, is it something you can add to the program so everyone has it as the basis to then personalise and modify as they desire. Seems a waste of every users time to replicate this. Thanks
Photo of Timothy

Timothy, Business Care Manager

  • 761 Posts
  • 220 Reply Likes
Hi David 

This article forms part of a series on developing your own clinical notes. The instructions above outline an example of what is possible using different clinical note tools and elements. In reality, it's probably not an ideal SOAP note template as you wouldn't need to have a body chart for each occurrence of the note. You would probably create the body chart as a standalone chart template to insert when necessary, which we will highlight in the next article.

Please click here to download the example above. To import this template into your Front Desk system:

Head to System > Clinical Note Templates and select Add on the right hand side.



Select Standard template.



From the File menu select Open and browse for you downloaded above to import the clinical note template. 



Further, we would be happy to make available for download additional templates made by other users that are happy to share their creations. If you make a post about your template and email the template to businesscare@smartsoft.com.au we will add the download link for other users at the bottom of your post. 

To export a template head to System > Clinical Notes Templates and double click on the template you would like to share.

Select Edit on the right hand side and when your template opens in the Front Desk Word Processor, from the File menu select Save As.

Photo of In Stride Health Clinic

In Stride Health Clinic

  • 124 Posts
  • 22 Reply Likes
Where can we print out these instructions?
Photo of david donkin

david donkin

  • 95 Posts
  • 33 Reply Likes
Thanks for download version Timothy, it will work as a good template and we can remove the body chart for the follow up ones. Appreciated.
Photo of Shelley Sloper

Shelley Sloper

  • 3 Posts
  • 0 Reply Likes
Hi, Im just starting to use this template - and I can't work out how to draw/put crosses or note on the body chart. Every time I try, it just moves the BC picture. Help??
Shelley
Photo of Steven

Steven, Business Care

  • 241 Posts
  • 68 Reply Likes
Hi Shelley. The quick answer is to double click on the image to bring up the drawing tools. We have prepared a new article that covers the Clinical Note Chart, Image and X-Ray tools at the following link:

https://community.smartsoft.com.au/smartsoft/topics/introduction-to-clinical-notes-charts-images-x-r...