The Template System
There are currently 35 different paper templates covering the broad scope of Family Practice. Each template (with a few one page exceptions) is a double-sided sheet of paper with detailed information related to particular complaints or diagnoses. The templates cover almost all of the major presenting complaints and can be used to document every patient visit from a simple ear-ache to the complex neurological/psychological presentation. The system is also thoughtfully and carefully designed to handle documenting multiple complaints, beyond the chief complaint. No more dreading the Oh-by-the-way-Doc conversation.
All of the templates have a similar layout. The History and Review of Systems come first and are on the left hand side. The Physical Exam is on the back, and the Impression and Plan are on the front lower right side. This allows for convenient review of previous diagnoses and disposition. The consistent layout makes the whole system easy to use - absolutely intuitive and simple.
Documenting with Records 1-2-3 templates is easy: you and your staff just (1) circle positives, (2) mark out negatives, and (3) leave blank those things not asked. This convention is very intuitive and soon becomes “second-nature”. This simple-to-use method increases doctor efficiency while simultaneously improving both the detail and legibility of the documentation.
The Templates
Symptom Based
Arranged Head to Toe
- General Template
- Headache
- Psychological Complaints
- Eye Complaints
- Upper Respiratory Complaints
- Neck / Back Pain
- Upper Extremity
- Chest Pain
- Hypertension
- Abdominal Complaints
- Skin Rash / Lesion
- Gynecological (Pre-Menses)
- Gynecological (Post-Menses)
- Urogenital Male
- Anorectal Problems
- Lower Extremity
- Problem List
- Telephone Consult
Diagnosis Based
Arranged Alphabetically
- Acne
- ADD/ADHD Evaluation
- ADD/ADHD Follow-Up
- Asthma
- Diabetes
- Geriatrics
- Hyperlipidemia
- Internal Medicine
- Laceration
- Obesity
- Physical Exam - Adolescent
- Physical Exam - Child
- Physical Exam - Female
- Physical Exam - Male
- Ingrown Toenail
- Urinary Tract Infection
- Immunization Administration
- Immunization Record
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