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Using custom note templates
Using custom note templates

Learn how to get started with custom note templates

Wesley Combs avatar
Written by Wesley Combs
Updated over a week ago

**Custom templates can be created and edited on web and desktop only. Once created custom templates can be used on any platform**

What Are Note Templates?

Note templates in Ambient Scribe allow you to predefine the structure and content of your clinical notes. By creating custom templates, you can specify the sections, details, and formatting to ensure that all your notes are consistent and comprehensive. These templates can be used for various types of patient encounters, from annual wellness checks to specific conditions like flu or strep throat.

How to create a template

You'll find the template editor in Settings > Templates. Here, you'll see your existing templates.

To create a new template, click the Create template button. This will open the template editor. Enter:

  • Name: Used to identify your template in the settings menu.

  • Instructions: Tell Ambient Scribe how to structure your notes and what information to capture.

  • Example note: Provide an example note to reinforce the structure and format of your notes.

Once you've finished, click Create template to create your template.

Using your custom templates

In Settings > Note, you'll find a Note template option, which allows you to select your default template. This template will be used by default when you create a note.

Switch note templates frequently? You can change your note selection before you generate your note.

Managing Your Templates

You can review and manage your created templates in the Settings > Templates by clicking for any note.

You can:

  • Edit an existing template: Select the template you want to modify, make your changes, and save.

  • Duplicate a template: Use this feature to create a similar template with slight modifications.

  • Delete a template: Remove templates that are no longer needed.

Tips to Get the Most Out of Your Templates

  • Be Detailed: Ensure your instructions are clear and comprehensive to avoid any ambiguity.

  • Use Standardized Sections: Follow common clinical note structures like SOAP (Subjective, Objective, Assessment, Plan) or H&P (History and Physical) to maintain consistency.

  • Regularly Review and Update: Periodically review your templates to ensure they meet current clinical guidelines and your practice’s needs.

  • Leverage Examples: Use the example note to illustrate the desired format and content, making it easier for Ambient Scribe to follow.

By creating and customizing your note templates in Ambient Scribe, you can streamline your documentation process, ensure consistency, and enhance the quality of your clinical notes.

Ambient scribe to Veradigm EHR Mapping Details

Many EHR's have specific sections on how the data is mapped in. Below are details on the Veradigm Integration and where the note sections are mapped to inside the VEHR.


Physical Examination (PE)

  • What to look for:

    • The exact text headers “Objective” and “Physical Exam”

  • How it works:

    • Our system will search your note for these headers.

    • If both are present, the content under both is combined.

  • Purpose:

    • This combined text is used to capture your physical exam findings and observations.

Review of Systems (ROS)

  • What to look for:

    • The exact text header “Review of Systems”.

  • How it works:

    • Only the text under this header is extracted.

  • Purpose:

    • This section is used for a systematic review of the patient’s body systems.

Reason for Visit (RFV)

  • What to look for:

    • The exact text header “Subjective”.

  • How it works:

    • Our system extracts all text within the “Subjective” section.

      • This includes any sub-headings such as “Chief Complaint”, “History of Present Illness (HPI)”, or “Past Medical History” that you might include.

  • Purpose:

    • This text captures the patient’s chief complaint and relevant history.

Assessment and Plan (AP)

  • What to look for:

    • The exact text headers “Assessment” and “Plan”.

  • How it works:

    • The system first extracts the text under “Assessment” and then the text under “Plan”.

      • These are combined in that order.

  • Purpose:

    • The combined text provides your diagnoses and treatment planning.

Important Note on Sub-Sections

Our system looks for these specific headers exactly as written. Even if you include additional sub-sections like “Chief Complaint” or “History of Present Illness,” they should be placed under the appropriate main header (typically “Subjective”) so they are processed correctly.

Example Layout:

Subjective:
- Chief Complaint:
- History of Present Illness:
- Past Medical History:
(All this content is mapped to RFV)

Review of Systems:
(This content is mapped to ROS)

Objective:
(This content is mapped to PE)
Physical Exam:
(If present, this content is also mapped to PE)

Assessment:
(This content is part of AP)
Plan:
(This content is also part of AP)

Using these exact section headers ensures that your notes are accurately extracted and organized by the system.

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