Choosing a note template

Edited

The ‘Note’ tab within your Nabla ‘Settings’ is where to find and edit your chosen template formatting. 

The ‘Note template’ drop-down is where you will find your selection of Nabla templates to choose from.

General Templates Available:

Template

Sections

SOAP

Subjective - Objective - Assessment - Plan

SOAP ("Assessment" & "Plan" merged)

Subjective - Objective - Assessment & Plan

SOAP ("Assessment" and "Plan" merged, PE and Tests)

Subjective - Objective - Physical Exam - Diagnostic tests ordered - Assessment & Plan

APSO

Assessment & Plan - Subjective - Objective

Multiple Sections

Chief complaint - History of present illness - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Plan - Prescription - Appointments

Multiple sections ("Assessment" and "Plan" merged)

Chief complaint - History of present illness - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment & Plan - Prescription - Appointments

Multiple Sections (“Assessment” and “Plan” merged) with ROS

Chief complaint - History of present illness - Review of systems - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Immunizations - Vitals - Physical exam - Lab results - Imaging results - Assessment & Plan  - Prescription - Appointments

Psychiatry (SOAP)

Subjective - Objective - Assessment - Plan

Psychiatry (multiple sections)

History of present illness - Chief complaint - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Mental status exam - Plan - Prescription - Appointments

Cardiology (multiple sections)

Chief complaint - History of present illness - Cardiovascular risk factors - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Plan - Prescription - Appointments

Diet (multiple sections)

Lifestyle - Medical history - Reason for visit and goal - Vitals - Food habits - Objective and advice - Appointment

Psychology (multiple sections)

Chief complaint - History of the present complaint - Mental health history - Social history - Mental status exam - Assessment - Plan - Appointments

Lactation (multiple sections)

Chief complaint - History of present illness - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Plan - Prescription - Appointments

Emergency medicine (multiple Sections)

Chief complaint - History of present illness - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Plan - Prescription - Appointments

Emergency medicine (SOAP)

Subjective - Objective - Assessment - Plan

Well Child Care (multiple sections)

Chief complaint - History of present illness - Well Child Care -Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Plan - Prescription - Appointments

Well Child Care (SOAP)

Subjective - Objective - Assessment - Plan

Oncology (multiple sections)

Chief complaint - History of present illness - Past medical history - Past surgical history - Past obstetric history - Family history - Social history - Allergies - Current medications - Vitals - Immunizations - Physical exam - Lab results - Imaging results - Assessment - Plan - Prescription - Appointments

Oncology (SOAP)

Subjective - Objective - Assessment - Plan

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