Customizable Documentation Templates

Standardize your clinical documentation with pre-built templates that adapt to your practice style

See Templates in Action Customization Guide

Consistent Formatting

Ensure every note follows your preferred structure and style

Save Time

Reduce documentation time with intelligent defaults and auto-formatting

Fully Customizable

Adapt templates to match your specialty and workflow

Allergies Template

Comprehensive allergy documentation with automatic categorization

Note Section

Template Preview:

Medical allergies: [list allergies, if no allergies put NKDA.]

Food allergies: [list allergies, if no allergies replace with None]

Seasonal allergies: [list allergies, if no allergies delete the row]

Indoor allergies: [list allergies, if no allergies delete the row]

Other allergies: [list allergies, if no allergies delete the row]

Customizable Elements:

Category labelsDefault values for no allergiesRow deletion rulesAdditional allergy categories

Pro tip: DAX Copilot automatically applies your template preferences during documentation

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Physical Exam Template

Systematic physical examination documentation with specialty-specific sections

Note Section

Template Preview:

General Appearance: [List findings, if not mentioned put Normal].
Vital signs: [List findings, if not mentioned put Within normal limits].
HEENT: [List findings, if not mentioned put Within normal limits].
Respiratory: [List findings, if not mentioned put Within normal limits].
Cardiovascular: [List findings, if not mentioned delete this row].
Gastrointestinal: [List findings, including Rectal, Male, if not mentioned delete this row].
Genitourinary: [List findings, prefixed Male or Female, if not mentioned delete this row].
Lymphatic: [List findings, if not mentioned delete this row].
Back, Musculoskeletal: [List findings, if not mentioned delete this row].
Extremities: [List findings, if not mentioned delete this row].
Skin: [List findings, if not mentioned put Warm and dry, no rash.]
Neurological: [List findings, if no data replace with Normal].
Psychiatric: [List findings, if not mentioned delete the row].
Other observations: [List findings, if not mentioned delete the row].

Customizable Elements:

System orderDefault normal findingsSpecialty-specific systemsRow deletion preferences

Pro tip: DAX Copilot automatically applies your template preferences during documentation

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Assessment and Plan Template

Structured diagnosis and treatment planning with clear action items

Note Section

Template Preview:

[Diagnosis One]
[Assessment narrative].

DIAGNOSTIC PLAN:

-[diagnostic plan including tests. Don't list this row if blank]
-[procedures. Don't list this row if blank]
-[other laboratory studies. Don't list this row if blank]

Treatment plan: [Treatment plan including patient education, pharmacotherapy if any, other therapeutic procedures. Don't list this row if blank].
Clinical decision making: [risks and benefits, alternatives. Don't list this row if blank].

[Repeat sections above for additional diagnoses]

Follow-up: [next scheduled visit, other. Remove this row and header if blank].

Customizable Elements:

Plan section headersBullet point formattingTreatment categoriesFollow-up structure

Pro tip: DAX Copilot automatically applies your template preferences during documentation

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Primary Care Encounter

Complete template for routine primary care visits

Full Encounter

Template Preview:

Chief Complaint: [Patient's main concern]

History of Present Illness:
[Detailed narrative of current symptoms, onset, duration, severity, associated symptoms]

Review of Systems:
Constitutional: [fever, weight loss, fatigue]
HEENT: [headache, vision changes, hearing loss]
Cardiovascular: [chest pain, palpitations, edema]
Respiratory: [shortness of breath, cough, wheezing]
[Additional systems as relevant]

Past Medical History: [List conditions]
Medications: [Current medications with dosages]
Allergies: [As per allergy template]

Physical Examination: [As per physical exam template]

Assessment and Plan: [As per assessment template]

Customizable Elements:

Section inclusion/exclusionROS comprehensivenessDefault valuesSpecialty-specific additions

Pro tip: DAX Copilot automatically applies your template preferences during documentation

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Emergency Medicine

Rapid documentation for emergency department encounters

Specialty

Template Preview:

Time of Arrival: [timestamp]
Mode of Arrival: [EMS/Private vehicle/Walk-in]
Chief Complaint: [Presenting symptom]

Triage Assessment:
Vital Signs: [BP, HR, RR, Temp, O2 sat, Pain scale]
Acuity Level: [1-5 ESI scale]

HPI: [OPQRST format - Onset, Provocation, Quality, Radiation, Severity, Time]

Primary Survey:
Airway: [Patent/Compromised]
Breathing: [Normal/Labored/Absent]
Circulation: [Stable/Unstable]
Disability: [Alert/Verbal/Pain/Unresponsive]
Exposure: [Notable findings]

[Continue with standard sections]

Customizable Elements:

Triage categoriesSurvey componentsTime stampsDisposition options

Pro tip: DAX Copilot automatically applies your template preferences during documentation

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Mental Health Session

Comprehensive psychiatric evaluation and therapy notes

Specialty

Template Preview:

Chief Complaint: [Patient's stated reason for visit]

History of Present Illness:
Mood: [Current mood state and duration]
Sleep: [Pattern, quality, changes]
Appetite: [Changes, weight fluctuation]
Energy: [Level, daily variation]
Concentration: [Ability to focus, memory issues]
Suicidal/Homicidal Ideation: [Deny/Present - if present, plan and means]

Mental Status Exam:
Appearance: [Grooming, attire, hygiene]
Behavior: [Cooperative, agitated, withdrawn]
Speech: [Rate, volume, tone]
Mood: [Patient's stated mood]
Affect: [Observed emotional state]
Thought Process: [Organized, tangential, circumstantial]
Thought Content: [Delusions, obsessions, preoccupations]
Insight/Judgment: [Good, fair, poor]

[Continue with assessment and treatment plan]

Customizable Elements:

MSE componentsRisk assessment scalesTherapy note formatMedication tracking

Pro tip: DAX Copilot automatically applies your template preferences during documentation

Try this template

How Template Customization Works

Choose Template

Select from our library or create your own custom templates

Customize Format

Adjust sections, defaults, and formatting to match your style

Auto-Apply

DAX Copilot automatically formats notes using your preferences

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