to the right of a line item.To create a new template from scratch:
1 In the information bar, click Admin > Manage Templates.
2 Click the Encounters tab.
3 Click <Organization Name> in the Select Template Level list.
4 Click History in the Select Template Type list.
5 Click Create New.
6 Click a category on the left-hand side of the page to add it to your template.
7 For each category in your template, do the following:
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Notes: • You cannot add line items to the Pregnancy History or Menstrual History categories. You can only add or remove the entire Pregnancy History or Menstrual History categories from a template. • You cannot modify the description of the Pregnancy History or Menstrual History line item. |
• To remove individual line items from the category, click to the right of a line item.
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Tip: Prior to saving the template, you can click the Restore link beside a removed item to view it again. |
• To remove an entire category, click to the right of a category name.
• To modify the description of a line item, click 
next to the item that you want to edit and change the description, as needed.
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Notes: • If a patient’s history already includes the line item that is modified, then the original line item description remains in the patient’s history. The next time the patient’s history is updated (using the template with the modified line item), you will see the original line item description as well as separate line item with the modified description. • If you want to view the system description for a modified line item, hover the pointer over the item. |
• To add a history item that is not included in the list:
a Click ICD-9, ICD-10, CPT® & HCPCS level II, or SNOMED only to indicate the type of code or description.
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Note: ICD-10 is only available for the Past Medical History category. |
b Type three or more characters of the code or description in the Other box and then select the item from the list.
If the item you want to add cannot be found in the database, type it in as free text.
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CPT ® copyright 2016 American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. |
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Notes: • CPT codes and descriptions are not available for Social History line items. • Free text items will not be included in reports or alerts, and are not easily shared with others using electronic formats such as CCD. |
c Click Add.
• To move individual line items in a category, position your pointer over the item and then drag and drop the item in a new location within the category.
Items cannot be moved into another category.
• To move an entire category, position your pointer over the category heading and then drag and drop the category in a new location.
8 Type a unique name for the template in the Template Name box.
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Note: Try to include details about your template in your template name to make it easier for yourself and other users to select the appropriate template from the library when creating encounter notes (for example, |
9 Click Save to add the template to your organization’s template library.
To create a new template based upon an existing master template:
1 In the information bar, click Admin > Manage Templates.
2 Click the Encounters tab.
3 Click Master Templates in the Select Template Level list.
4 Click History in the Select Template Type list.
5 Click the master template that you want to use in the Select a Template to Copy list.
6 See steps 6-7 of To create a new template from scratch:.
7 Type an unique name for the template in the Template Name box.
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Note: Try to include details about your template in your template name to make it easier for yourself and other users to select the appropriate template from the library when creating encounter notes (for example, |
8 Click Save to add the template to your organization’s template library.