User Guide — Configure Exam Templates

When you create a local template, we recommend that you start by copying an existing global template to ensure that the template contains the appropriate contradictions and names for each finding. To customize the local template, you can add additional paragraphs, sentences, and findings using the available global template data or by creating custom template elements.

Templates are constructed as a series of "paragraphs," which contain "sentences" and "findings."

• Paragraphs are the highest level of organization, usually a body system or area.
• Sentences are the second level of organization.
• Findings represent a unique clinical concept and are attached to a unique identifier that is used to run reports and generate an Evaluation and Management (E&M) code using the E&M coder.

The global template data available in athenaOne is from a system of standardized medical terminology called MEDCIN. Each finding contains a unique underlying MEDCIN ID that is used by the system to determine the finding to update. The MEDCIN ID does not change, even if the finding is renamed.

In the sample below, the paragraph called Constitutional has a sentence called General Appearance, which has five findings: well-nourished, in no acute distress, obese, cachectic, ill-appearing.

If a finding is renamed (if obese is renamed as overweight), it will still share the same MEDCIN ID as the original finding. Therefore, if both findings exist within the same encounter, selecting or updating one finding will automatically select or update the other finding.

Important: Updates to finding names must preserve the meaning of the original finding name to ensure consistency across templates.

After you create the elements that you need, you can use any of the following pages to select paragraphs, sentences, and findings, and arrange them to make the templates that you need:

• History of Present Illness Templates
• Physical Exam Templates
• Procedure Templates
• Review of Systems Templates
• Well Child Review of Systems Templates
• Test Interpretation Templates

History of Present Illness and Physical Exam templates used for the physical therapy specialty

 

History of Present Illness and Physical Exam templates used for the physical therapy specialty include sentences and findings that you can use as patient goals in the Assessment / Plan section and that you can track over time in physical therapy episodes.

• (G) appears next to sentences and findings that you can use in the Assessment / Plan Patient Goals section.
• (T) appears next to sentences that you can track in the physical therapy episode Progress section.

You can drag and drop the elements in a template to rearrange the content.

Tip: Use the Expand/Collapse all paragraphs option for easier editing.

1. Left-click any paragraph, sentence, or finding heading.
2. Hold down the cursor while dragging the entire section to the new location.
3. Release the cursor button.
4. To save the new arrangement, click Update.

Tip: Look for the Preview Box (dotted-line outline of a box) before you drop the section into place.

You can report on clinical template usage at your practice. To make this possible, we add the new Clinical Template Audit Report to the Report Library. This report shows whether your practice uses the templates you build and highlights opportunities for cleanup.