Encounter Note Text Examples

Overview

Review example text and templates to help you write clear, consistent encounter notes in Cerbo. These samples provide guidance on documenting patient interactions effectively.

Example - Follow up Visit

[[pt_name]] is a [[pt_age]] year old [[pt_sex]] who is here for a follow up visit.

[[pt_rxs]]

[[pt_supplements]]

[[pt_allergies]]

[[pt_pmh]]

Vitals:

pt_vitals (this is the name of a separate Chart Part template - after taking the vitals, you would click after pt_vitals and select that Chart Part to insert the patient's most recently taken vitals readings)

Labs: reviewed

PLAN

1) 

2) 

3) 

4) 

Example - Follow up Visit

CURRENT ISSUES:

[[pt_rxs]]

[[pt_supplements]]

PERTINENT LAB/ IMAGING DATA: 

Diet/ nutrition: 

Movement: 

Rest/ restore/ sleep: 

Stress: 

Energy:

physical_exam (this is the name of a separate fillable charting template form. When you're ready to do the physical exam, you would click at the end of physical_exam, and then select the template from the suggested matches to pull up the physical exam form)

--------

DX/ASSESSMENT:

--------

PLAN: 

--------

ISSUES TO FOLLOW UP:

Example - Follow Up Visit

VITALS:

pt_vitals (this is the name of a separate Chart Part template - after taking the vitals, you would click after pt_vitals and select that Chart Part to insert the patient's most recently taken vitals readings)

CC: 

    1. {???} (this is a placeholder variable, you would click the tab key to select the next placeholder, and start typing to replace it. This enables you to quickly jump to different fields.)

    2. {???}

    3. {???}  

DIET - 

LIFESTYLE: 

    - Exercise/Movement - {???}

    - Stress Management - {???}

DIGESTION:  {???}

SLEEP: {???}

ENERGY:  {???}

MOOD: {???}

OBJECTIVE: {???}

physical_exam (this is the name of a separate fillable charting template form. When you're ready to do the physical exam, you would click at the end of physical_exam, and then select the template from the suggested matches to pull up the physical exam form)

[[pt_rxs]] 

[[pt_supplements]]

IMPRESSION: {???}

PLAN: {???}

Spent 60 mins with patient, 50% in counseling and coordination of care. 

Example - Functional Medicine Intake

________________________________________

REASON FOR VISIT

----------

 [[pt_name]]  is a [[pt_age]] [[pt_sex]] here for a visit.

________________________________________

HISTORY & TIMELINE

----------

________________________________________

CURRENT MEDS, SUPPLEMENTS, ALLERGIES

----------

[[pt_allergies]]

[[pt_rxs]]

[[pt_supplements]]

________________________________________

REVIEW OF SYSTEMS

----------

ros (this is the name of a separate fillable charting template form. When you're ready to do the physical exam, you would click at the end of ros, and then select the template from the suggested matches to pull up the desired ROS fillable form)

________________________________________

LIFESTYLE

----------

________________________________________

MEDICAL HISTORY

----------

[[pt_pmh]]

[[pt_note_pmh]]

________________________________________

SOCIAL & FAMILY HISTORY

----------

[[pt_note_social]]

________________________________________

EXAM

----------

physical_exam (this is the name of a separate fillable charting template form. When you're ready to do the physical exam, you would click at the end of physical_exam, and then select the template from the suggested matches to pull up the desired physical exam fillable form)

________________________________________

LABS

----------

________________________________________

NARRATIVE

----------

________________________________________

RECOMMENDATIONS

----------

Example - Functional Medicine Intake 

__________________________

~~~ S ~~~

COMMENTS: 

HEALTH GOALS: 

CHIEF COMPLAINT: 

TIMELINE

     * Infancy -

     * Childhood -

     * Teenage -

     * 20's -

     * 30's - 

     * 40's -

     * 50's -

POSSIBLE TRIGGERING EVENT(S): 

GI: 

DIET: 

ETOH: 

[[pt_allergies]]

SLEEP: 

STRESS: 

EXERCISE: 

SOCIAL: 

SUPPORT: 

MOLD EXPOSURE: 

TRAVEL: 

TOXINS: 

PAST MEDICAL HX, SURGERIES: 

[[pt_pmn]]

[[pt_note_pmh]]

FAMILY MEDICAL HX: 

WHAT HAS HELPED: 

[[pt_rxs]]

[[pt_supplements]]

__________________________

~~~ O ~~~

MSQ: 

LABS:

__________________________

~~~ A ~~~

PRINCIPAL PROBLEMS:

__________________________

~~~ P ~~~

Example - Functional Medicine Intake

VITALS:

pt_vitals (this is the name of a separate Chart Part template - after taking the vitals, you would click after pt_vitals and select that Chart Part to insert the patient's most recently taken vitals readings)

CC

    1. 

    2. 

    3. 

HPI

PMHx

[[pt_pmh]]

[[pt_note_pmh]]

CHILDHOOD HX

    - Illness - 

    - Trauma - 

FAMILY HX

    - Mother - 

    - Father - 

    - Sister - 

    - Brother -  

SHx: 

    - Employment - 

    - Support system - 

DIET - 

    - Breakfast - 

    - Lunch - 

    - Dinner - 

    - Snacks - 

    - Water/ liquids - 

    - Desserts - 

LIFESTYLE: 

    - Caffeine - 

    - Alcohol -

    - Smoking -

    - Exercise/ Movement - 

    - Stress Management -

    - Digestion -

    - Sleep -  

    - Stress -

    - Energy -

    - Mood -

    - Exposures -

ros (this is the name of a separate fillable charting template form. When you're ready to do the physical exam, you would click at the end of ros, and then select the template from the suggested matches to pull up the desired ROS fillable form)

[[pt_allergies]]

[[pt_rxs]]

[[pt_supplements]]

OBJECTIVE: 

physical_exam (this is the name of a separate fillable charting template form. When you're ready to do the physical exam, you would click at the end of physical_exam, and then select the template from the suggested matches to pull up the physical exam form)

IMPRESSION: 

PLAN: 

Spent 90 mins with patient, 50% in counseling and coordination of care.