Inpatient & Surgical Notes
Launch dotScribe then type in the boxes below to see what dotScribe can do for you.
History Templates
BEGINNER
problem.history.specialty
copd.history
stroke.history
pna.history
ADVANCED
,hpiproblemspecialty
,hpicopd
,hpistroke
,hpipna
dotScribe MASTER
copdhi
strokehi
pnahis
All of dotScribe's history templates are standardized and include common findings to increase your speed and accuracy. A "pertinent negatives" review of systems is also included in each history to help you avoid missing key symptoms. Try type-searching with any of the methods above. Specialty inclusion is optional.
Progress Notes (more coming soon)
BEGINNER
problem.progress.specialty
reassess.progress
mobility.progress
tpn.pogress
ADVANCED
,pnproblemspecialty
,pnreassess
,pnmobility
,pntpn
dotScribe MASTER
reasspn
pnmobil
tpnprog
dotScribe's progress notes facilitate rapid updates on patient conditions and treatment responses for your daily rounds. Try type-searching with any of the methods above. Specialty inclusion is optional.
Nursing Progress Notes (additions based on demand)
BEGINNER
problem.npn.specialty
ngtube.npn
pcapump.npn
bathing.npn
ADVANCED
,npnproblemspecialty
,npnngtube
,npnpcapump
,npnbathing
dotScribe MASTER
ngnpn
pcanpn
bathnpn
dotScribe's nursing progress notes streamline documentation by offering structured templates for common nursing tasks. Try type-searching with any of the methods above. Specialty inclusion is optional. More content is forthcoming.
Review of Systems Templates
BEGINNER
problem.ros
pneumonia.ros
chestpain.ros
altered.ros
ADVANCED
,rosproblem
,rospna
,roschestpain
,rosams
dotScribe MASTER
rospna
roschp
amsros
dotScribe has systems-based templates as well as problem-specific negative review of systems. Problem-specific templates contain negatives and red-flag symptoms that should not be missed. Try type-searching with any of the methods above.
Physical Exam Templates
BEGINNER
problem.exam
appendicitis.exam
bleed.exam
tbi.exam
msk.exam
ADVANCED
,examproblem
,examappendicitis
,exambleed
,examtbi
,exammsk
dotScribe MASTER
appenexam
bleedexam
tbiex
mskexa
dotScribe has a robust library of disease-specific exam findings as well as normal exam findings by system. Try type-searching with any of the methods above.
Assessment & Plan Templates
BEGINNER
problem.plan.specialty
asthma.plan
jaundice.plan
uti.plan
ADVANCED
,approblemspecialty
,apasthma
,apjaundice
,aputi
dotScribe MASTER
asthplan
jaundiplan
utiplan
dotScribe's assessment and plan library of templates include discussions with the patient, treatment plans, and further recommendations as necessary. Try type-searching with any of the methods above. Specialty inclusion is optional.
Complete SOAP Notes (additions based on demand)
BEGINNER
problem.soap.specialty
acl.soap
knee.soap
ADVANCED
,soapproblemspecialty
,soapacl
,soapknee
dotScribe MASTER
aclsoap
kneesoap
dotScribe's ever-growing library includes a variety of ways to document, including SOAP notes. Try type-searching with any of the methods above. Specialty inclusion is optional. dotScribe's SOAP note library is currently limited due to lack of demand and EHR incompatibility.
Procedure Notes
BEGINNER
procedurename.procedurenote
paracentesis.procedurenote
arterialline.proc
chesttube.proc
ADVANCED
,proc.procedurename
,proc.paracentesis
,proc.arterialline
,proc.chestube
dotScribe MASTER
paraproc
arterproc
ctproc
dotScribe's procedure templates are designed to save you as much time as possible. Procedure templates (,proc) are different than (,procz) templates. PROCZ templates are rapid links to external instructional resources on how to perform specific procedures. Visit our Rapid Links tutorial for more information on the ,procz library. Try type-searching with any of the methods above.
Operative Notes (additions based on demand)
BEGINNER
procedurename.operativenote.specialty
ADVANCED
,opprocedurenamespecialty
dotScribe's operative note library is currently limited but many surgery-specific templates are forthcoming.
PostOperative Notes (additions based on demand)
BEGINNER
problem.postop.specialty
spine.postop
hip.postop
knee.postop
ADVANCED
,popproblemspecialty
,popspine
,pophip
,popknee
dotScribe MASTER
spinepost
hippost
kneepost
Try type-searching with any of the methods above. Specialty inclusion is optional. dotScribe's postoperative note library is currently limited but many surgery-specific templates are forthcoming.
Discharge Summary Notes (more coming soon)
BEGINNER
problem.discharge.specialty
hipreplacement.discharge
gastricsleeve.discharge
appendicitis.discharge
ADVANCED
,dcsproblemspecialty
,dcshipreplacement
,dcsgastricsleeve
,dcsappendicitis
dotScribe MASTER
dcship
dcsgastr
appendidis
Try type-searching with any of the methods above. Specialty inclusion is optional.
Common Statements & Phrases
BEGINNER
topic.common
billing.common
counsel.common
alcohol.common
ADVANCED
,xtopic
,xbilling
,xcounsel
,xalcohol
dotScribe MASTER
x.bil
x.couns
x.alc
These templates were created for all the odds and ends types of phrases that don't quite fit anywhere else. Think of the "X" as the missing variable in your notes. Try type-searching with any of the methods above.