This page expands on the visit types listed on the Office Visit page and goes into more detail on what each visit type means, how to prepare, and what your note should cover. Use the visit type shown in the Type or Office Notes column of the Schedule tab to guide your approach to each patient.
What it is: A same-day or short-notice visit for a new or worsening problem (cough, UTI symptoms, back pain, or a rash). These are usually added to your schedule within a few days of the request and may appear mid-day, so check your schedule regularly for additions.
Focus of the note: Keep the HPI tightly focused on the presenting complaint. A brief, relevant history and a focused exam are appropriate. You don't need a comprehensive review of every chronic condition unless it's contributing to the acute issue.
Tips:
• Pre-chart briefly, but expect the reason for visit to be the main driver of the encounter. Plan to spend most of your time on history-taking in the room. It may help to read up on the differential and exam feratures of the complaint ahead of time to do more patinent-centered learning.
• If the visit uncovers a second, unrelated concern, it's fine to address it, but don't let it derail the primary complaint.
• Give return precautions and clear follow-up instructions in the Wrap-up, since these patients often won't be back on a fixed schedule.
Dotphrase: .DOUGNOTEACUTE
@CC@ — Pulls in the chief complaint/reason for visit from scheduling. Usually needs no edits.
Subjective — Header for the objective section
@PATPREFNAME@ / @AGE@ / @GENDERID@ — Auto-pull the patient's preferred name, age, and gender identity into the ID statement. Replace *** with the patient's pertinent active past medical history.
HPI — Free text the HPI: onset, location, duration, character, aggravating/alleviating factors, radiation, timing (OLDCAART), plus pertinent positive and negative review of systems.
@CMED@ — Pulls in the current medication list. Use it to reconcile medications with the patient during the visit.
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. Document pertinent positive and negative findings, and only include systems you actually examined.
@ASSESSPLAN@ — Pulls forward the orders that were associated to the patient's diagnoses
Assessment and Plan — Header for the assessment and plan.
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Review each for accuracy before signing. For acute problems, we expect a differential and thought process.
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. Complete Wrap-up before checkout so this section isn't blank.
What it is: The bread-and-butter visit type for established patients returning to check in on chronic conditions (diabetes, hypertension, COPD, etc.), review labs, or adjust medications.
Focus of the note: Structure the visit around each active chronic condition being addressed — how it's controlled, what's changed since the last visit, and your plan for each. This is a good visit type to practice problem-oriented documentation. You do not have to address every problem. The focus should be on active problems, problems being addressed by our office and not specialists. Agenda set at the beginning of the visit to focus the visit to those problems.
Tips:
• Pre-chart by reviewing labs, imaging, and any interval visits (ED, specialist, hospital) since the last office visit.
• Use this visit to reconcile medications and the problem list (see the Office Visit page for details) — these are expected at every follow-up.
• Address preventive care gaps that are due (vaccines, screenings) when time allows, even if they weren't the reason for the visit.
Dotphrase: .DOUGNOTEFOLLOWUP
@CC@ — Pulls in the chief complaint/reason for visit from scheduling. Usually needs no edits.
Subjective — Header for the subjective section
@PATPREFNAME@ / @AGE@ / @GENDERID@ — Auto-pull the patient's preferred name, age, and gender identity into the ID statement. Replace *** with the patient's pertinent active past medical history.
"Patient presents for a follow up visit for chronic medical conditions" — Standard opening line for this visit type. Edit it if it doesn't fit the encounter.
HPI — Free text to replace ***. Address the status of each chronic condition being managed today: control, symptoms, medication response, and anything that's changed since the last visit.
@HMDUE@ — Pulls in health maintenance items that are due (screenings, vaccines, labs). Use it to spot preventive care gaps you can address during the visit.
@CMED@ — Pulls in the current medication list. Use it to reconcile medications with the patient during the visit.
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. Document pertinent positive and negative findings, and only include systems you actually examined.
@ASSESSPLAN@ — Pulls forward the orders that were associated to the patient's diagnoses
Assessment and Plan — Header for the assessment and plan.
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Review each for accuracy before signing. For chronic problems, we expect MEAT documentation (monitor, evaluate, address/assess, treat).
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. Complete Wrap-up before checkout so this section isn't blank.
What is it: Annual wellness visit — a comprehensive, age- and sex-appropriate preventive exam focused on screening, immunizations, and health maintenance rather than management of an acute complaint.
Focus of the note: Structure the visit around preventive care — what screenings, labs, and immunizations are due, updating history and risk factors, and a head-to-toe exam. Chronic conditions can be acknowledged, but if a condition needs active management or medication adjustment, it should generally be addressed as a separate problem-focused follow-up rather than folded into this visit. Agenda set at the beginning of the visit to confirm this is a wellness visit and to surface any additional concerns the patient wants addressed.
Tips:
Pre-chart by reviewing what health maintenance items are due (screenings, vaccines, labs) before the patient arrives, so you can address them efficiently during the visit.
Use this visit to reconcile medications and the problem list — these are expected at every annual visit, even though the focus isn't management of active problems.
If a chronic condition is uncontrolled or needs a medication change, document it but consider scheduling a separate follow-up visit to address it fully — this keeps the preventive visit from being billed/coded as a problem-focused encounter.
Update social history (tobacco, alcohol, exercise, diet, safety) and family history, since these often go stale between annual visits.
Dotphrase: .DOUGNOTEPHYSICAL
Patient ID: @PATPREFNAME@ @AGE@ @GENDERID@ — Auto-pulls the patient's preferred name, age, and gender identity into the ID statement.
HPI: header for HPI
"Patient presents today for annual preventive examination." — Standard opening line for this visit type. Edit if it doesn't fit the encounter.
Preventative Care: — Free-text section covering key lifestyle/risk domains reviewed at every physical.
Diet: *** — Replace with a brief note on current eating habits/any concerns.
Exercise: *** — Replace with frequency/type of activity.
Sexual activity: *** — Replace with relevant sexual history pertinent to preventive care (partners, protection, concerns).
Contraception: *** — Replace with current method, or "N/A" if not applicable.
Occupation: *** — Replace with current job and any relevant occupational exposures/risks.
Living situation: *** — Replace with household/living situation relevant to safety and support.
Depression screening — Header cueing the screening tools below; document the result/interpretation, not just the score.
@FLOW(22483)@ — Pulls in the flowsheet value for this specific screening tool (e.g., PHQ-2/PHQ-9 depending on clinic build). Confirm it pulled the most recent completed screening.
@FLOW(2100100060)@ — Pulls in a second flowsheet value tied to this visit type (verify which tool this ID corresponds to in your build). Review for completeness before signing.
@FLOWVAL(22484)@ — Pulls in a specific flowsheet value (e.g., a screening score total). Double-check it matches what was administered today.
@HMDUE@ — Pulls in health maintenance items that are due (screenings, vaccines, labs). Review each with the patient and document what was ordered, declined, or already current.
@PMH@ — Pulls in the patient's past medical history. Review for accuracy and update if anything has changed.
@CMED@ — Pulls in the current medication list. Use it to reconcile medications with the patient during the visit.
Objective: Header for objective section
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. For preventive physicals, document a comprehensive exam across systems rather than one limited to a single complaint.
@ASSESSPLAN@ — Pulls forward the orders associated with the patient's diagnoses.
Assessment and Plan: Header for A/P section
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Keep chronic condition notes brief (stable vs. needs follow-up); reserve full MEAT documentation for a dedicated follow-up visit if a condition needs active management.
Patient instructions: Header for patient intstructions section
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab, including preventive counseling given and timing of the next annual exam. Complete Wrap-up before checkout so this section isn't blank.
What it is: A visit following a patient's discharge from a hospitalization, meant to catch problems early and prevent readmission. These are often scheduled quickly (within about a week to two weeks of discharge) per Tower Health policy.
Focus of the note: Review the discharge summary before the visit. Your note should reconcile what happened during the hospitalization with the outpatient plan: confirm the patient understands their diagnosis and discharge instructions, reconcile all medication changes (new, stopped, and dose-adjusted), confirm follow-up with any specialists recommended at discharge, and make sure pending labs/imaging or incidental findings from the hospitalization are tracked.
Tips:
• These visits often take longer than a standard follow-up because of the medication reconciliation and record review involved, plan your pre-charting time accordingly.
• Flag any discrepancies between the discharge summary and what the patient reports to your preceptor.
Dotphrase: .DOUGNOTETOC
TOC VISIT — Static header identifying the visit type at the top of the note. Not a SmartLink; leave it as is.
Subjective — Header for the subjective section.
@PATPREFNAME@ / @AGE@ / @GENDERID@ — Auto-pull the patient's preferred name, age, and gender identity into the ID statement.
"Patient is here for post hospital follow up appointment." — Static opening line for this visit type.
@MRDADMD@ — Auto-pulls the hospital admission date.
"...with diagnosis of ***" — Replace *** with the admitting diagnosis from the discharge summary.
@MRDDISD@ — Auto-pulls the hospital discharge date.
@LACESCORE@ — Auto-pulls the patient's LACE score (readmission risk score) calculated at discharge.
"Hospitalization course ***" — Replace *** with a brief summary of what happened during the hospitalization: relevant events, procedures, or changes in condition.
"Medication changes per discharge instructions: ***" — Replace *** with a summary of medications started, stopped, or changed at discharge.
"Pertinent labs from admission: ***" — Replace *** with relevant lab results and trends from the hospitalization.
"Pertinent imaging from admission: ***" — Replace *** with relevant imaging studies and results from the hospitalization.
"History reviewed:" — Header introducing the auto-pulled history section below.
@PMH@ — Auto-pulls past medical history. Confirm nothing relevant to the hospitalization is missing.
@PSH@ — Auto-pulls past surgical history.
@FAMHX@ — Auto-pulls family history.
@CMED@ — Pulls in the current medication list. Reconcile this carefully — discharge medications often differ from what's on file, and catching discrepancies is a core purpose of the TOC visit.
@ALLERGY@ — Auto-pulls documented allergies.
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. Document pertinent positive and negative findings, and only include systems you actually examined.
@ASSESSPLAN@ — Pulls forward orders that were associated with the patient's diagnoses.
Assessment and Plan — Header for the assessment and plan.
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Review each for accuracy before signing. For chronic problems, we expect MEAT documentation (Monitor, Evaluate, Address/Assess, Treat).
The four attestation bullets — ("I have reviewed the discharge summary...", medication reconciliation, follow-up orders, patient/caregiver education) — Fixed, required documentation language for TOC visits. Leave them in the note as written, and make sure each one is actually true before you sign — don't just leave them as boilerplate.
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. Complete Wrap-up before checkout so this section isn't blank.
What it is: A visit for a patient establishing care with the clinic for the first time (not previously seen by any provider here).
Focus of the note: This should include an expanded history — past medical history, past surgical history, family history, social history, and medication list should all be reviewed and documented in detail, not just updated. Take the time to build a full problem list rather than relying on what's carried over from outside records.
Tips:
• Budget extra time for chart review before the visit if outside records were sent over — new patients often bring records from a prior practice that need to be reconciled into the chart.
• This is a good visit to set the tone for the patient relationship — clarify how to reach the office, use MyChart, and what to expect from follow-up care.
Dotphrase: .DOUGNOTENEW
Subjective — Header for the subjective section.
@PATPREFNAME@ / @AGE@ / @GENDERID@ — Auto-pull the patient's preferred name, age, and gender identity into the ID statement.
"Patient presents to establish care" — Standard opening line for this visit type. Edit it if it doesn't fit (for example, reword for an Internal Transfer).
HPI — Free text. Note the reason the patient is establishing care and any current concerns they want addressed at this visit.
"Transfer from ***" — Replace *** with where the patient is transferring from (an outside practice, or another provider within Tower Health Network for an Internal Transfer).
"Chronic medical conditions include ***" — Replace *** with a brief summary list of the patient's known chronic conditions, to orient the reader before the detailed history pulls in below. If they have chronic conditions like type II diabetes, asthma, COPD, hypertension, etc., you should give more history regarding that such as when they were diagnosed, any medications tried in the past, and any complications.
@PMH@ — Auto-pulls the patient's past medical history. Since this is likely the first time it's being captured at this clinic, confirm it's complete and accurate with the patient rather than accepting it at face value.
@PSH@ — Auto-pulls past surgical history. Same as above — confirm completeness directly with the patient.
@CMED@ — Pulls in the current medication list. For a new patient this is a chance to build a complete, accurate list from scratch, not just reconcile an existing one.
@ALLERGY@ — Auto-pulls documented allergies. Confirm with the patient and make sure the specific reaction is documented for each allergy.
@SOCH@ — Auto-pulls social history. Because this may be the first time it's been captured for this patient, build it out fully rather than accepting a sparse pull. At a first visit, aim to cover:
• Living situation: who they live with, housing stability, home environment
• Occupation and work environment: current job, physical demands, relevant exposures
• Relationship status and support system
• Tobacco use: type, amount, duration, interest in quitting
• Alcohol use: type, frequency, quantity
• Other substance use: recreational or non-prescribed drug use
• Diet and exercise habits
• Safety: seatbelt use, firearms in the home, intimate partner violence screening when appropriate
• Sexual history: partners, protection use, STI risk, as relevant
• Advance directives / healthcare proxy: time permitting
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. Document pertinent positive and negative findings, and only include systems you actually examined.
@ASSESSPLAN@ — Pulls forward orders that were associated with the patient's diagnoses. For a true new patient this may pull in little or nothing; for an Internal Transfer it will likely pull in more, since the patient already has activity within Tower Health Network.
Assessment and Plan — Header for the assessment and plan.
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Review each for accuracy before signing. For chronic problems, we expect MEAT documentation (Monitor, Evaluate, Address/Assess, Treat).
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. Complete Wrap-up before checkout so this section isn't blank.
What it is: Similar to a new patient visit, but for a patient transferring care from another provider within Tower Health Network rather than an outside practice.
Focus of the note: Uses the same new-patient note template, with the same expectation of an expanded history. The advantage here is that prior records are already in Epic, so chart review is usually faster than a true new patient with outside records.
Tips:
• Don't assume the prior Tower Health note captured everything, still confirm history directly with the patient rather than just copying forward.
• Note why the patient is transferring (insurance, location, provider preference) if relevant, as it can be useful context for future visits.
Dotphrase: .DOUGNOTENEW
Subjective — Header for the subjective section.
@PATPREFNAME@ / @AGE@ / @GENDERID@ — Auto-pull the patient's preferred name, age, and gender identity into the ID statement.
"Patient presents to establish care" — Standard opening line for this visit type. Edit it if it doesn't fit (for example, reword for an Internal Transfer).
HPI — Free text. Note the reason the patient is establishing care and any current concerns they want addressed at this visit.
"Transfer from ***" — Replace *** with where the patient is transferring from (an outside practice, or another provider within Tower Health Network for an Internal Transfer).
"Chronic medical conditions include ***" — Replace *** with a brief summary list of the patient's known chronic conditions, to orient the reader before the detailed history pulls in below. If they have chronic conditions like type II diabetes, asthma, COPD, hypertension, etc., you should give more history regarding that such as when they were diagnosed, any medications tried in the past, and any complications.
@PMH@ — Auto-pulls the patient's past medical history. Since this is likely the first time it's being captured at this clinic, confirm it's complete and accurate with the patient rather than accepting it at face value.
@PSH@ — Auto-pulls past surgical history. Same as above — confirm completeness directly with the patient.
@CMED@ — Pulls in the current medication list. For a new patient this is a chance to build a complete, accurate list from scratch, not just reconcile an existing one.
@ALLERGY@ — Auto-pulls documented allergies. Confirm with the patient and make sure the specific reaction is documented for each allergy.
@SOCH@ — Auto-pulls social history. Because this may be the first time it's been captured for this patient, build it out fully rather than accepting a sparse pull. At a first visit, aim to cover:
• Living situation: who they live with, housing stability, home environment
• Occupation and work environment: current job, physical demands, relevant exposures
• Relationship status and support system
• Tobacco use: type, amount, duration, interest in quitting
• Alcohol use: type, frequency, quantity
• Other substance use: recreational or non-prescribed drug use
• Diet and exercise habits
• Safety: seatbelt use, firearms in the home, intimate partner violence screening when appropriate
• Sexual history: partners, protection use, STI risk, as relevant
• Advance directives / healthcare proxy: time permitting
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. Document pertinent positive and negative findings, and only include systems you actually examined.
@ASSESSPLAN@ — Pulls forward orders that were associated with the patient's diagnoses. For a true new patient this may pull in little or nothing; for an Internal Transfer it will likely pull in more, since the patient already has activity within Tower Health Network.
Assessment and Plan — Header for the assessment and plan.
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Review each for accuracy before signing. For chronic problems, we expect MEAT documentation (Monitor, Evaluate, Address/Assess, Treat).
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. Complete Wrap-up before checkout so this section isn't blank.
What it is: An evaluation of a patient's risk for an upcoming surgery, optimization of chronic medical conditions for surgery and recommendations on medication management in the peri-operative period. There is usually an accompanying form from the surgical office specifying what needs to be assessed.
Focus of the note: Review the form for the specific requirements first. The MA should provide it to you, so check with them first. It often dictates required labs, EKG, or specialist clearance (e.g., cardiology). Your note should address relevant comorbidities and their current control (cardiac, pulmonary, diabetes, anticoagulation), a focused exam, and a clear statement of risk and whether they can proceed with surgery or any testing or optimization is needed prior to surgery.
Tips:
• Check anticoagulant and antiplatelet medications early. Timing around surgery is a common point of confusion and may need coordination with the surgical team and generally is the main recommendation the surgical team will be looking for.
• If proceeding to surgery is contingent on further testing, make sure the plan and timeline are explicit in the note and communicated to the patient and surgical office.
Dot phrase: Pre-op clearance (SmartText: TWR AMB PRIMARY CARE PREOP CLEARANCE [39407]). You will use the pre-op risk assesment under the plan tab to complete the documentation below. Please review with a preceptor before seeing the patient if you you need assistance in accessing and reviewing the pre op risk assessment
{⚡Quick Links...} — (Last Note in Specialty Snapshot, Labs/Imaging/Results Review, Full Problem List) — These are Quick Links, not auto-inserted text. Click one if you need to pull up that information for reference; they don't insert anything into the note on their own.
@NAME@ / @AGE@ / @SEX@ — Auto-pull the patient's name, age, and sex into the opening statement. Note this template uses legal name/sex (relevant for surgical and anesthesia documentation) rather than preferred name/gender identity used elsewhere.
The three @CERMSGREFRESH(...)@ links after "presents for preoperative evaluation..." — Auto-pull the referring surgeon's name, the planned procedure, and the surgery date from the referral/consult order, in that order. Verify these against the form from the surgical office — they're only as accurate as the order that was placed.
{Anesthesia Options:40521} — SmartList: select the planned anesthesia type.
{anesthesia problems:23954} — SmartList: select any known anesthesia issues (e.g., prior difficult airway, malignant hyperthermia history), or indicate none.
@SOCH@ — Auto-pulls social history.
@PREOPASSESSMENTSTART@ / @PREOPASSESSMENTEND@ — Section markers that bound the auto-formatted risk assessment block. Don't edit or delete these; content between them adjusts automatically based on what you fill in.
{LOW/INTERMEDIATE/HIGH:40511} — SmartList: select the surgery's risk category.
The High/Intermediate/Low risk examples list — Reference text to help you pick the right risk category above. It's guidance, not something you need to fill in.
Functional Status Assessment / Surgical Risks @CERMSGREFRESH(...)@ links — Auto-pull the functional status and calculated surgical risk output from the Preop risk tool (Plan tab of the Screenings Navigator). Complete the risk tool first so these pull in correctly.
@CERMSGREFRESH(1224510:40260;1224816:40362)@ — Auto-pulls additional risk-calculator output (e.g., cardiac risk index) from the Preop risk tool.
@CERMSGREFRESH(259190:59158)@ — Auto-pulls relevant labs/imaging for review.
"Cardiac Studies (if available or applicable):" — Static header.
@ECG@ — Auto-pulls EKG results, if available.
@ROSBYAGE@ — Inserts an age-appropriate review of systems template.
@PHYSEXAMTRH@ — Inserts the exam template for this note (the preop-specific version of the standard physical exam SmartLink). Document pertinent positive and negative findings.
@PREOPPLANBEGIN@ / @PREOPPLANSTOP@ — Section markers that bound the auto-formatted plan section, paired the same way as the assessment markers above. Don't edit or delete these.
{Ensure review, documentation and risk stratification of all HCC coding:39022} — Reminder text prompting you to make sure HCC-relevant chronic conditions are documented and risk-stratified in this note. It's guidance, not literal text to keep.
@DIAGPOCORD@ — Pulls in diagnosis-linked orders as part of problem-oriented, diagnosis-aware charting. Worth getting familiar with, but the note works fine with the standard workflow if you don't use it.
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. The new PREOPPTINSTRUCTIONS SmartText appears as a speed button here to help you build preop-specific patient instructions, which flow into the note.
"Post-Operative Recovery: Patient currently {lives with:40524}" — SmartList: select the patient's living/support situation, relevant to post-op recovery planning.
{Consider documenting if there are specific concerns or notations that could impact recovery:39022} — Reminder text, not something to leave in verbatim — document any recovery-relevant concerns here if applicable.
@CERMSGREFRESH(2109222021:59434)@ — Auto-pulls additional consult/order detail relevant to the plan.
"Patient {IS/NOT:23228} medically optimized for surgery with the above recommendations." — SmartList: select IS or IS NOT. This is the key attestation statement for the visit — every note needs this completed before signing.
What it is: A preventive visit required annually for Medicare patients (and sometimes dual-eligible patients), separate in purpose from a routine follow-up. This visit type requires two separate notes: an Annual Wellness Visit note and a routine follow-up note. As a resident, you are only responsible for the follow-up note. Your preceptor process handles the wellness note until you are a PGY3.
Focus of the note: Treat your note like a standard office visit follow-up (your portion) — address active chronic conditions, medication reconciliation, and problem list updates, as you would for any other follow-up.
Tips:
• Because two notes are being generated for one encounter, double check with your preceptor early on if you're unsure which part of the visit you're responsible for.
• These visits can run long since two distinct sets of requirements are being met in one encounter. In particular, rooming the patient may take a while if they have to complete the Medicare wellness quiestionnaire
Dotphrase: .DOUGNOTEFOLLOWUP and Medicare Wellness (again you are not responsible for the medicare wellness note)
@CC@ — Pulls in the chief complaint/reason for visit from scheduling. Usually needs no edits.
Subjective — Header for the subjective section
@PATPREFNAME@ / @AGE@ / @GENDERID@ — Auto-pull the patient's preferred name, age, and gender identity into the ID statement. Replace *** with the patient's pertinent active past medical history.
"Patient presents for a follow up visit for chronic medical conditions" — Standard opening line for this visit type. Edit it if it doesn't fit the encounter.
HPI — Free text to replace ***. Address the status of each chronic condition being managed today: control, symptoms, medication response, and anything that's changed since the last visit.
@HMDUE@ — Pulls in health maintenance items that are due (screenings, vaccines, labs). Use it to spot preventive care gaps you can address during the visit.
@CMED@ — Pulls in the current medication list. Use it to reconcile medications with the patient during the visit.
@VS@ — Pulls in vitals recorded at rooming. Double-check anything abnormal, especially an elevated blood pressure, per clinic policy.
@PHYSICALEXAM@ — Inserts your exam template. Document pertinent positive and negative findings, and only include systems you actually examined.
@ASSESSPLAN@ — Pulls forward the orders that were associated to the patient's diagnoses
Assessment and Plan — Header for the assessment and plan.
@PROBAPNOTES@ — Pulls in problem-specific assessment/plan notes tied to each diagnosis on the problem list. Review each for accuracy before signing. For chronic problems, we expect MEAT documentation (monitor, evaluate, address/assess, treat).
@PATINSTR@ — Pulls in whatever you entered in the Wrap-up tab. Complete Wrap-up before checkout so this section isn't blank.
What it is: An acute, injury-focused visit for a patient presenting after a motor vehicle collision — not a preventive or chronic-disease-maintenance visit. Unlike a routine follow-up, documentation here may later be reviewed for insurance, legal, or third-party liability purposes, so it needs to be more explicit and self-contained than a typical chronic-care note (avoid vague language or copy-forwarded text). You cannot bill MVA insurance for anything not realated to the MVA so it is important to clarify with the patient at the start of the insurance if they plan to use MVA insurance.
Focus of the note: Document the mechanism of injury and a focused history/exam of the affected body region(s), rather than a general chronic-condition check-in. Even if the patient has other active problems, this note should center on the accident: what happened, what hurts, what's changed since, and what the plan is for the injury itself.
Tips:
Get specific mechanism details early — date/time of the accident, role in vehicle (driver/passenger), speed if known, restraint use (seatbelt/airbag deployment), and whether EMS/ER was involved that day. These details matter for both clinical decision-making and any later record review.
Screen for red flags at every MVA visit regardless of how minor the accident sounded — loss of consciousness, neck/back pain with neuro symptoms, chest pain, abdominal pain, or worsening symptoms — and document that you asked, even if negative.
Be precise rather than templated: since these notes can end up supporting insurance or legal claims, avoid boilerplate phrasing that doesn't reflect what the patient actually reported or what you actually examined.
If imaging, PT, or specialist referral is indicated, document the reasoning clearly, since that's often what gets scrutinized later.
Dotphrase: you can use the .DOUGNOTEACUTE dotphrase