Encounter Templates

Encounter Templates help you create reusable, standardized clinical documentation for patient visits. They streamline workflows, improve consistency, and significantly reduce documentation time for healthcare providers.

Overview

Encounter Templates allow clinics and hospitals to define structured formats for common visit types. By using predefined sections and default values, providers can document encounters faster while maintaining accuracy and completeness.

Key Benefits

• ⚡ Save Time: Reduce documentation time by 5–10 minutes per patient
• ✅ Standardized Records: Maintain consistency across providers
• 📋 Complete Documentation: Ensure no critical fields are missed
• 🔄 Reusable Templates: Apply templates to similar visit types
• 📊 Better Reporting: Capture structured data for analytics and audits

Common Encounter Template Types

General Practice Templates

• Annual Physical Examination
• Follow-Up Visit
• Acute Illness Visit
• Preventive Care Visit
• Chronic Disease Management

Specialty Templates

• Diabetes Care: HbA1c review, medication adjustments
• Cardiology: Post-MI follow-up, hypertension monitoring
• Pediatrics: Well-child visits, vaccination visits
• OB/GYN: Prenatal visits, annual exams

Creating an Encounter Template

Step 1: Open the Template Builder

1. Navigate to Medical → Encounter Templates
2. Click Add New Template

Step 2: Enter Basic Template Information

Template Name: Annual Physical Examination
Description: Comprehensive annual health checkup for adults
Category: Preventive Care
Status: Active

Step 3: Define Template Sections

A. Chief Complaint

Section Name: Chief Complaint
Field Type: Textarea
Label: Reason for Visit
Default Text: Annual physical examination
Required: Yes

B. Vital Signs

Section Name: Vital Signs (Auto-included)
Fields:
- Blood Pressure
- Heart Rate
- Temperature
- Weight
- Height
- BMI (Automatically calculated)

C. Review of Systems

Section Name: Review of Systems
Field Type: Checkboxes
Options:
- Constitutional: No fever, chills, fatigue
- Eyes: No vision changes
- ENT: No hearing loss or sore throat
- Cardiovascular: No chest pain or palpitations
- Respiratory: No cough or shortness of breath
- Gastrointestinal: No nausea, vomiting, diarrhea
- Genitourinary: No dysuria or frequency
- Musculoskeletal: No joint pain
- Neurological: No headache or dizziness
- Skin: No rashes
- All systems normal

D. Physical Examination

Section Name: Physical Examination
Field Types: Text and Checkboxes
- General Appearance: Well-appearing
- HEENT: Normocephalic, PERRLA
- Neck: Supple, no masses
- Heart: Regular rate and rhythm
- Lungs: Clear to auscultation
- Abdomen: Soft, non-tender
- Extremities: No edema
- Neurological: Alert and oriented x3

E. Assessment & Plan

Section Name: Assessment
Field Type: Textarea
Label: Clinical Assessment
Placeholder: Summary of findings and health status

Section Name: Plan
Field Type: Textarea
Label: Treatment Plan
Placeholder: Recommendations, referrals, follow-up

F. Prescription Section

Section Name: Prescriptions
Integration: Automatically loads prescription module
Functionality: Add medications directly within the encounter

Step 4: Save and Activate Template

Click Save Template.
The template is now ready for use during patient encounters.

Using Encounter Templates During Visits

Step-by-Step Workflow

1. Open Patient Record
   • Go to Patients → Select Patient
   • Or open directly from Appointments → Start Encounter
2. Create a New Encounter
   • Click New Encounter
   • Or select Start from Appointment
3. Select a Template
   • Choose a template from the dropdown list
   • Example: Annual Physical Examination
   • Click Load Template
4. Template Auto-Populates
   • All sections load automatically
   • Default values are prefilled
   • Ready for customization
5. Enter Patient-Specific Information
   • Record vital signs
   • Select review of systems
   • Document physical exam findings
   • Complete assessment and plan
   • Prescribe medications if required
6. Save Encounter
   • Data is saved to the patient record
   • Becomes part of the permanent medical history

Encounter Template Examples

Template Example 1: Diabetes Follow-Up

Template Name: Diabetes Management Visit

Sections Include:

• Chief Complaint (Default: Diabetes follow-up)
• Vital Signs with emphasis on weight tracking
• Diabetes-specific measurements (Blood glucose, HbA1c)
• Medication review and adherence
• Self-monitoring habits
• Complication screening (neuropathy, vision, renal function)
• Lifestyle assessment (diet, exercise, weight changes)
• Clinical assessment and treatment plan
• Lab orders, referrals, and follow-up scheduling

Template Example 2: Pediatric Well-Child Visit

Template Name: Well-Child Checkup

Sections Include:

• Visit details and age calculation
• Growth measurements with percentiles
• Developmental milestone checklists
• Feeding and nutrition review
• Comprehensive physical examination
• Immunizations administered during the visit
• Parent education and anticipatory guidance
• Next visit scheduling and vaccine reminders

Template Example 3: Hypertension Management

Template Name: Hypertension Visit

Sections Include:

• Chief complaint with default BP check
• Blood pressure-focused vitals
• Medication review and adherence
• Home BP monitoring review
• Lifestyle risk factors (diet, exercise, smoking)
• Target organ damage assessment
• Blood pressure classification
• Medication changes, lab orders, and follow-up plan

Advanced Encounter Template Features

Prescription Integration

Templates can include predefined medication lists relevant to the condition.
Selected medications are automatically added to the prescription module.

Lab Order Templates

Include commonly ordered lab tests as checkboxes.
Selected tests are automatically converted into lab orders.

Follow-Up Scheduling

Providers can select follow-up intervals directly within the template, with appointment booking pre-filled for convenience.

Best Practices for Encounter Templates

Naming Conventions

Recommended:

• Adult Annual Physical (18–64)
• Type 2 Diabetes Follow-Up
• Pediatric Well-Child – 12 Months

Avoid:

• Template 1
• Checkup
• DM

Logical Section Order

1. Chief Complaint
2. Vital Signs
3. History and Review of Systems
4. Physical Examination
5. Assessment
6. Plan

Use Default Values Wisely

• Pre-fill normal findings
• Save time during routine visits
• Easily modify when abnormalities exist

Required Fields

Mark only the critical fields as required:

• Vital signs
• Assessment
• Plan

Avoid making every checkbox mandatory.

Managing Encounter Templates

Editing Templates

• Updates apply only to future encounters
• Existing encounter records remain unchanged

Duplicating Templates

• Duplicate templates to create variations
• Ideal for similar visit types (initial vs follow-up)

Deactivating Templates

• Set template status to Inactive instead of deleting
• Preserves historical data
• Can be reactivated anytime

Encounter Template Reports

Available Metrics:

• Most frequently used templates
• Templates never used
• Average documentation time
• Completion rates

Use reports to optimize workflows and standardize care across providers.

Troubleshooting Common Issues

Template Not Loading

• Confirm template status is Active
• Verify user permissions
• Clear browser cache
• Check for JavaScript errors

Fields Not Saving

• Ensure required fields are completed
• Verify database connectivity
• Check validation rules and error logs

Template Feels Too Long

• Split into logical sections
• Remove rarely used fields
• Create separate templates for specific scenarios

Related Features

• Custom Forms Builder – Additional structured data collection
• Medical Reports – Generate clinical and administrative reports
• Print Templates – Create professional printable documents