Note Template Commands

This series of commands is intended to provide the structure of basic note templates used in medical documentation. You should feel free to modify the content and names of these note templates as suits your needs.

Command Name / Result
Brief Procedure Template / BRIEF PROCEDURE REPORT:
Proposed Procedures:
1. [01]
Actual Procedures:
1. [02]
Post Operative Diagnosis:
1. [03]
Surgeons:
1. [04]
Anesthesia: [05]
Estimated Blood Loss: [06]
Drains and Tubes: [07]
Findings, Complications, and Other Information: [08]
Discharge Summary Template / DISCHARGE SUMMARY
DISCHARGE DIAGNOSES:
1. [01]
PROCEDURES:
1. [02]
HISTORY OF PRESENTATION: [03]
HOSPITAL COURSE: [04]
DISCHARGE MEDICATIONS: [05]
FOLLOW-UP: [06]
Inpatient Admit Template / ADMISSION HISTORY AND PHYSICAL EXAMINATION:
CHIEF COMPLAINT: [01]
HISTORY OF PRESENT ILLNESS: [02]
PAST MEDICAL HISTORY:
1. [03]
MEDICATIONS: [04]
ALLERGIES: [05]
SOCIAL HISTORY: [06]
FAMILY HISTORY: [07]
REVIEW OF SYSTEMS: [08]
PHYSICAL EXAMINATION: [09]
ADDITIONAL DATA: [10]
ASSESSMENT: [11]
PLAN:
1. [12]
Inpatient Consult Template / INPATIENT CARDIOLOGY CONSULTATION - [01]
REQUESTING PHYSICIAN: [02]
REASON FOR CONSULT: [03]
HISTORY OF PRESENT ILLNESS: [04]
PAST MEDICAL HISTORY:
1. [05]
MEDICATIONS: [06]
ALLERGIES: [07]
SOCIAL HISTORY: [08]
FAMILY HISTORY: [09]
REVIEW OF SYSTEMS: [10]
PHYSICAL EXAMINATION: [11]
ADDITIONAL DATA: [12]
ASSESSMENT: [13]
PLAN:
1. [14]
Inpatient Progress Note Template / INPATIENT PROGRESS NOTE
CLINICAL PROBLEMS:
1. [01]
24 HOUR EVENTS: [02]
EXAMINATION: [03]
PERTINENT DATA:
[04]
ASSESSMENT: [05]
PLAN:
1. [06]
Mid Level Admit Template / CARDIOLOGY ADMISSION NOTE
This patient has been admitted to the Cardiology Service under my care for the management of [01]. The patient has been seen in conjunction with a mid-level provider, ProviderName. I have independently interviewed and examined the patient and agree with the documentation provided by ProviderName.
Clinical History: In brief, [02]
Pertinent Physical Findings:
Examination: [03]
Pertinent Data:
Labs: [04]
Assessment: [05]
Plan:
1. I have discussed the results of my cardiovascular overview and impressions with the patient and/or appropriate family
2. Options for management were reviewed
3. [06]
Mid Level Back-up Template / CARDIOLOGY DAILY PROGRESS NOTE
The patient was seen today with the associate provider, [ProviderName]. I have independently interviewed and examined the patient and reviewed pertinent historical, laboratory, and other data, and concur fully with documented findings.
In brief, [01]
Physical Examination: [02]
Pertinent Data:
Labs: [03]
Assessment: [04]
Plans:
1. I have discussed the results of my impressions with the patient and/or appropriate family
2. Options for management were reviewed
3. [05]
New Patient Evaluation / NEW PATIENT HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT: [01]
HISTORY OF PRESENT ILLNESS: [02]
PAST MEDICAL HISTORY:
1. [03]
MEDICATIONS: [04]
ALLERGIES: [05]
SOCIAL HISTORY: [06]
FAMILY HISTORY: [07]
REVIEW OF SYSTEMS: [08]
PHYSICAL EXAMINATION: [09]
ADDITIONAL DATA: [10]
ASSESSMENT: [11]
PLAN:
1. [12]
New Patient Template / NEW PATIENT HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT: [01]
HISTORY OF PRESENT ILLNESS: [02]
PAST MEDICAL HISTORY:
1. [03]
MEDICATIONS: [04]
ALLERGIES: [05]
SOCIAL HISTORY: [06]
FAMILY HISTORY: [07]
REVIEW OF SYSTEMS: [08]
PHYSICAL EXAMINATION: [09]
ADDITIONAL DATA: [10]
ASSESSMENT: [11]
PLAN:
1. [12]
Outpatient Follow-up Template Two / OUTPATIENT FOLLOW-UP NOTE
SUBJECTIVE: [01]
OBJECTIVE:
Physical Exam: [02]
DIAGNOSES:
1.[03]
DISCUSSION: [03]
PLAN:
1.[04]
Outpatient History and Physical / NEW PATIENT HISTORY & PHYSICAL
CHIEF COMPLAINT: [01]
HISTORY OF PRESENT ILLNESS: [02]
PAST MEDICAL HISTORY:
1. [03]
MEDICATIONS: [04]
ALLERGIES: [05]
SOCIAL HISTORY: [06]
FAMILY HISTORY: [07]
REVIEW OF SYSTEMS: [08]
PHYSICAL EXAMINATION: [09]
ADDITIONAL DATA: [10]
ASSESSMENT: [11]
PLAN:
1. [12]
Resident Admit Template / STAFF ADMISSION NOTE
Clinical History: This patient was admitted to our institution with the chief complaint of: [01].
The patient was seen in conjunction with Dr. [ProviderName]. I have independently interviewed and examined the patient and reviewed pertinent historical, laboratory, and other data and concur fully with documented findings.
In brief, [02]
Physical Examination: [03]
Pertinent Data:
[04]
Assessment: [05]
Recommendations:
1. I have discussed the results of my impressions with the patient and/or appropriate family
2. Options for management were reviewed
3. [06]
Resident Consult Template / CONSULTATION NOTE
Requesting Physician: [01]
Clinical History: The Cardiology Service was asked to evaluate this patient regarding: [02].
The patient was seen in conjunction with Dr. [ProviderName]. I have independently interviewed and examined the patient and reviewed pertinent historical, laboratory, and other data, and concur fully with documented findings.
In brief, [03]
Physical Examination: [04]
Pertinent Data: [05]
Assessment: [06]
Recommendations:
1. I have discussed the results of my clinical impressions with the patient and/or appropriate family
2. Options for management were reviewed
3.[07]
Thank you for allowing me to assist in the care of this patient. For questions or to discuss the case further, please contact me.
Staff Admission Addendum / STAFF INPATIENT ADMISSION NOTE:
This patient was seen today with [ProviderName] and was personally interviewed and examined. All of the data referred to below was personally reviewed. I agree fully with documentation and provide the following additional comments.
Briefly, [01]
Assessment:[02]
Plan:
1.[03]

Notes:

  1. These commands were created for the personal use of the author and are shared on a “use at your risk” basis. You are advised to use these commands only when they accurately reflect your own findings, management strategies, counseling documentation, etc.
  2. The actual Dragon commands corresponding with this documentation are found in separate .dat and XML files which can be downloaded and imported into your version of Dragon
  3. You are free to share these commands, including the download files, but may not publish or sell them without the express permission of Speech Recognition Solutions, LLC or Jon Wahrenberger, MD.