Choosing a note template
The ‘Template’ tab within your Nabla ‘Settings’ is where to find and edit your chosen template formatting.
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 |
Emergency medicine w/ MDM | History of present illness - Vitals - Physical exam - Results - MDM - Disposition |
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 |
Orthopedic - New Patient Intake | Chief complaint - History of present illness - Past medical history - Past surgical history - Current medications - allergies - Family history - Social history - Vitals - Physical exam - Lab results - Imaging review - Assessment/Plan |
Orthopedic - Follow up | Subjective - Objective - Imaging - Assessment/Plan |
OB/GYN - New Pregnancy Intake | Chief complaint - History of present illness - Past medical history - Past surgical history - Obstetric History - Family history - Social history - Allergies - Current medications - Immunizations - Vitals - Physical exam - Labs - Imaging - Assessment/Plan |
OB/GYN Prenatal Follow up | Subjective - Objective - Lab results - Imaging results - Assessment - Plan - Medications - Appointments |
Podiatry | Chief complaint - History of present illness - Review of systems - Past medical history - Past surgical history - Family history - Social history - Allergies - Current medications - Immunizations - Vitals - Physical exam - Lab results - Imaging results - Assessment - Procedures performed - Plan - Prescriptions - Patient education - Appointments |