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Common Medical Scribe Template Types

1. Emergency Department (ED) Full Visit: Comprehensive template for documenting an entire ED encounter from arrival to disposition.
2. ED HPI (History of Present Illness) Only: Focused template for detailing the story of the patient's chief complaint in the ED.
3. Primary Care New Patient: Template for gathering extensive history and baseline information for a patient new to the practice.
4. Primary Care Established Patient/Follow-up: Streamlined template for routine follow-up visits, focusing on interval changes and ongoing issues.
5. Annual Physical Exam: Template covering preventative care, screenings, and comprehensive review for yearly check-ups.
6. Urgent Care Visit: Designed for acute, non-life-threatening conditions often seen in walk-in clinics.
7. Cardiology Consultation: Template for documenting findings and recommendations when a cardiologist evaluates a patient.
8. Cardiology Follow-up: Specific template for monitoring ongoing cardiac conditions (e.g., HTN, CHF, CAD).
9. Orthopedics New Patient (Injury Specific): Focused on a specific musculoskeletal injury, mechanism, and exam findings.
10. Orthopedics Post-Operative Visit: Template for documenting recovery progress, wound check, and plan after surgery.
11. Neurology Consultation (e.g., Headache, Seizure): Specialized template for complex neurological histories and detailed neuro exams.
12. Neurology Follow-up: Used for monitoring chronic neurological conditions like epilepsy, MS, or Parkinson's.
13. Gastroenterology (GI) Procedure Note (e.g., EGD, Colonoscopy): Documents findings, interventions, and follow-up for endoscopic procedures.
14. GI Clinic Visit: Template for evaluating digestive system complaints like GERD, IBD, or abdominal pain.
15. Pulmonology Consultation (e.g., SOB, Cough): For evaluating respiratory symptoms and conditions like asthma or COPD.
16. Pulmonology Follow-up: Tracks progress of chronic lung diseases and treatment adjustments.
17. Pediatric Well Child Check: Age-specific templates covering growth, development, immunizations, and anticipatory guidance.
18. Pediatric Sick Visit: Template for documenting acute illnesses in children (e.g., fever, ear infection, rash).
19. OB/GYN New OB Intake: Comprehensive template for the first visit of a new pregnancy.
20. OB/GYN Routine Prenatal Visit: Focused template for monitoring maternal and fetal well-being during pregnancy.
21. OB/GYN Annual Well Woman Exam: Covers gynecological health, screenings (Pap, mammogram), and contraception.
22. Dermatology New Patient/Consult: Template for describing skin lesions, rashes, and patient history related to skin conditions.
23. Dermatology Procedure Note (e.g., Biopsy, Excision): Documents minor skin procedures performed in the office.
24. Psychiatry Initial Evaluation: Extensive template for gathering detailed psychiatric history, mental status exam, and diagnostic impression.
25. Psychiatry Follow-up/Med Management: Focuses on symptom changes, medication effects/side effects, and therapy progress.
26. Inpatient Admission H&P (History & Physical): Comprehensive note documenting reason for admission, detailed history, exam, and initial plan.
27. Inpatient Progress Note (SOAP Note): Daily note tracking patient's status (Subjective, Objective, Assessment, Plan) during hospitalization.
28. Inpatient Discharge Summary: Summarizes the hospital course, final diagnoses, discharge medications, and follow-up instructions.
29. Surgical Consultation (Pre-Op): Documents indication for surgery, patient evaluation, discussion of risks/benefits, and surgical plan.
30. Surgical Post-Operative Hospital Note: Daily note tracking recovery immediately following surgery in the hospital.
31. Telemedicine Visit: Adapted template for virtual encounters, often focusing more on history and visual assessment.
32. Physical Therapy Evaluation: Documents therapist's assessment, functional limitations, goals, and treatment plan.
33. Occupational Therapy Evaluation: Focuses on activities of daily living (ADLs), fine motor skills, and adaptive needs.
34. Pain Management Consultation: Detailed template for chronic pain history, prior treatments, and multimodal pain plan.
35. Pain Management Procedure Note (e.g., Injection): Documents specific interventional pain procedures.
36. Rheumatology Consultation: For evaluating systemic autoimmune and inflammatory joint diseases.
37. Endocrinology Visit (e.g., Diabetes, Thyroid): Template focused on managing hormonal disorders.
38. Urology Consultation: For evaluating urinary tract and male reproductive system issues.
39. Nephrology Visit: Specialized for kidney disease evaluation and management (e.g., CKD, ESRD).
40. Ophthalmology Visit: Template for documenting eye exams, visual acuity, and eye conditions.
41. ENT (Otolaryngology) Visit: For evaluating ear, nose, and throat complaints.
42. Allergy & Immunology Visit: Focuses on allergic reactions, asthma, and immune deficiencies.
43. Sports Medicine Visit: Geared towards athletic injuries, concussion management, and return-to-play decisions.
44. Geriatric Comprehensive Assessment: Multidimensional template addressing medical, functional, cognitive, and psychosocial aspects of elderly patients.
45. Wound Care Visit: Documents wound characteristics, measurements, treatment provided, and healing progress.
46. Procedure-Specific HPI (e.g., Laceration Repair): Mini-template focusing just on the history relevant to a specific minor procedure.
47. Review of Systems (ROS) Checklist: Standalone template or section for quickly documenting a comprehensive or focused ROS.
48. Physical Exam (PE) Template (System-Based): Organizes findings by body system (e.g., Cardiovascular, Respiratory, Neuro).
49. Medical Decision Making (MDM) Summary: Structured template to outline complexity, data reviewed, and risk involved in patient care decisions.
50. Patient Instructions/Handout Template: Scribe might help populate standardized instructions based on the visit findings and plan.