Create & Use a Clinical Document Template

Overview

Learn how to safely create templates so you can pre-populate commonly used comments, notes, or information during clinical treatment documentation. You are able to create multiple templates for a clinical document.

This may save you time, but please proceed with caution as each client should receive attentive and personal care, and patient health information (PHI) should not be saved in another patient's clinical document. 

Create a Clinical Document Template

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Add a New Clinical Document

1. Click on the Clinical/Charting module and then click Add.
2. Use the pick list to select a client.
3. If you have programs, select a Program.
4. Select a clinical document by clicking the form's radio button .
5. Click OK.

Fill Out the Template

1. Delete any client-specific data such as name, diagnosis, or address.
   • You will not be able to delete client information if the field is not an editable field. But this information will not populate when using the template in the future. 
2. Fill out the form with the re-usable or common information. 
   • This information will be saved as a starting point when this template is chosen for a new clinical document. 
     
3. Select the Template drop-down and click one of the following:
   • Add this as a public template - everyone in the agency can see and use.
   • Add this as a private template - only the creator can see and use.
     

     NOTE: If a change to a current template is needed in the future, select the template, make the changes and then saved it as a new template with an updated name. Once the new template appears in the drop-down list, you can delete the old template.

     
      
4. Name the template.
   • The title should be generic and should NOT contain PHI.
     
   • Now the next time you add a new clinical document for that specific form number, you will have the option to select the template. 

Use a Template

1. Add a new clinical document.
2. Select a template from the Template drop-down.
   • The clinical document will fill in the previously populated fields.
     
3. Complete the form with specific client data.
   • Your additions will not change the template.

Delete a Saved Template

1. Open a new clinical document.
2. Select a template from the Template drop-down.
3. Click Delete.
   

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