Medical & Surgical Note Templates (Index)

Last updated: Nov 2025

This page lists our medicine and surgery templates so you can find the right one fast. Each template card explains who it helps, what’s included, and how to use it with your EHR via the Nudge Chrome extension (edit-before-save, no API keys).

How to use these templates (quick)

1. Capture the visit (or upload audio) to generate the draft.

2. Review and adjust sections (HPI/ROS/Exam, Imaging, Assessment, Plan, postop fields, etc.).

3. In your EHR, open a new note and launch the Nudge extension → choose client + note type → confirm field mapping (edit-before-save).

4. Save & sign off.
   
   

Primary Care (IM/FP)

Use for internal medicine/family practice encounters.

Template card format (repeat for each template):

• Template name — visit type
  Who it helps: brief role(s).
  Sections: list key sections.
  When to use: one-line scenario.
  EHR mapping: HPI/Subjective, Exam, Assessment, Plan (and any extras).
  
  

Examples (fill these with the exact names from your gallery):

• New Patient Visit (IM/FP Primary Care) — evaluation
  Who it helps: PCPs onboarding new patients.
  Sections: Presenting Problem, HPI, ROS (optional), Exam, Assessment, Plan, Preventive prompts.
  When to use: first visit; establishes baselines and screenings.
  EHR mapping: HPI/Subjective, Exam, Assessment, Plan.

• Acute Care Visit (IM/FP Primary Care) — same-day problem
  Who it helps: PCPs handling acute complaints.
  Sections: HPI, Focused Exam, Assessment, Plan; work note/instructions optional.
  When to use: single-issue visits (e.g., URI, UTI symptoms).
  EHR mapping: HPI, Exam, Assessment, Plan.

• Office Procedure Note (IM/FP Primary Care) — in-clinic procedure
  Who it helps: PCPs doing minor procedures.
  Sections: Indication, Consent, Procedure Steps, Findings, Complications, Post-care Plan.
  When to use: lesion removal, I&D, joint injection, etc.
  EHR mapping: Procedure/Op note fields + Plan.

• Telemedicine Follow-Up (IM/FP Primary Care) — virtual visit
  Who it helps: PCPs managing chronic issues remotely.
  Sections: HPI update, Home vitals (optional), Assessment, Plan, Safety/return precautions.
  When to use: stable chronic follow-ups, results review.
  EHR mapping: HPI, Assessment, Plan.

• Annual/Preventive Visit (IM/FP Primary Care) — wellness
  Who it helps: PCPs completing annuals.
  Sections: History, Risk factors, Exam, Preventive services, Counseling, Plan.
  When to use: AWV/wellness visits with screening prompts.
  EHR mapping: Preventive/Wellness sections + Plan.
  
  

Sports Medicine

• Concussion: Initial Evaluation (Sports Med)
  Who it helps: sports med, urgent concussion clinics.
  Sections: Mechanism, Symptoms, Neuro exam, SCAT/vestibular screens, Return-to-play Plan.
  When to use: first post-injury assessment.
  EHR mapping: HPI, Neuro/MSK Exam, Assessment, Plan.

• Concussion: Follow-Up (Sports Med)
  Updates symptoms/testing and adjusts progression stages.

• Pre-Participation Sports Clearance (Sports Med)
  Screening, risk factors, exam, clearance decision, restrictions.

• Post-Op Clearance (Sports Med)
  Focused postop exam; readiness for activity; PT milestones.
  
  

Orthopedic Surgery

• New Patient Evaluation (Orthopedic Surgery)
  Who it helps: ortho clinics assessing new MSK complaints.
  Sections: HPI, MSK Exam, Imaging/Studies, Assessment, Plan.
  When to use: initial ortho consult (knee/shoulder/spine, etc.).
  EHR mapping: HPI, Exam, Imaging/Results, Assessment, Plan.

• Follow-Up (Orthopedic Surgery)
  Interval changes, repeat exam, imaging review, plan updates.

• Postoperative Follow-Up (Orthopedic Surgery)
  Wound status, ROM, weight-bearing restrictions, PT protocol, red flags; next visit.

• Office Procedure Note (Orthopedic Surgery)
  Indication, Consent, Steps, Findings, Implants (if any), Post-care Plan.
  
  

Dermatology

• Follow-Up (Dermatology)
  HPI, Skin exam (location, morphology), Assessment (dx list), Plan (tx, biopsy, follow-up).

• Procedure/Excision Note (Dermatology)
  Indication, lesion details, margins, closure, specimen sent, post-op care.
  
  

Telemedicine

• Telemedicine Follow-Up (General Medicine)
  Problem update, remote vitals, assessment, plan, safety/return precautions.
  
  

Medication/Refill & Admin

• Medication Refill
  Med list, adherence, side effects, labs (if applicable), plan with monitoring.

• Administrative Visit/Forms
  Purpose, required sections completed, counseling provided, plan/next steps.
  
  

Results (2025)

Most notes are ready in <60–90 seconds after capture.
Teams report 4–6 hrs/week saved and higher consistency across providers.

FAQs

Can I force specific fields (e.g., ROS, measures, postop items)?
Yes. Mark sections as required and block export until completed.

Does this work with our EHR?
Use the Nudge Chrome extension to map sections into your EHR’s fields; you review and confirm before saving.

Can we standardize phrasing across the group?
Yes. Set organization-wide defaults (bullets vs paragraphs, required sections, terminology) and apply them to all providers.