Note: The below templates are from a test database, your templates can be changed to suit your needs.
Within the Clinical section of TM3 there are a number of different template types. These are Consultation, Discharge, Modality, Assessment and Previous Medical History templates. All of these templates will be pre-populated with information but can be changed to suit your needs. Clinical Templates can be accessed by going to Settings > Clinical > Clinical Templates.
Consultation templates control what template appear on a patient's first appointment and any other appointments after this. You can have First and Follow Up Consultation templates or you can have one consultation that will be the template for all of your appointments. Information such as admission date, current medications, vaccinations, allergies and lifestyle factors such as how many units of alcohol they drink a week will appear here. This will be linked to the first appointment of the patient's case and will only appear once per case. Below is an example of a first consultation from the templates section.
The next image shows what way the template will display from the case.
The follow up consultation template will then appear for any other appointments of that case. This will have information like changes or improvements from the last appointment and any follow up notes. There is a function to add any treatments or modalities into the follow up consultation template. The names of these templates can be changed within the settings. Below is an example of a follow up consultation from the templates section.
The next image shows the follow up template with an added assessment.
You can have multiple first and follow up templates within Clinical Templates but only one first and follow up template can be active at any time. The active first and follow up consultation will have an orange First and Follow Up box on the template. To change this choose the Make First/Follow Up options on whatever template you want to be active.
The discharge template will contain information about the discharge of the patient like discharge date, discharge pain scale and the outcome of the treatment. More fields can be added and the template can be changed to suit your needs. A discharge template from within the Clinical Templates section can be viewed below.
The next image shows the Discharge template from the case.
Like the Summary and Consultation templates you can have more than one discharge template but only one can be active. The template that is currently active will have an orange Default box beside the template name. To make another the default template click the Make Default option.
Modalities are treatments the practitioner will carry out for patients. These can range from applying cryotherapy, rock tape or something as simple as stretching advice. Unlike the Discharge templates there does not have to be a default modality. This means you can create and use as many modalities as you wish. In a consultation you can use as many modalities are needed for that particular consultation. Modalities can be added to both the First and Follow Up consultations.
Modalities can be set up in different ways. The modality below is set to have predefined selections and some additional notes.
However, the following modality is less complicated and only contains a text option.
Assessment templates would include such information as your SOAP notes, information about the injury like the side of injury and any loss of power. Different assessments will be set up for different body sites or if you were assessing reflexes for a body part after injury. Like Modalities; you can create and use as many Assessments as needed in a particular consultation. Assessments can be added to both the First and Follow Up consultations.
An assessment from the Clinical Templates section can be viewed below. Notice we have selected Yes on the Body Site specific option at the top. This opens up the Subjective Findings selections.
The below image shows the same assessment but within the case section. Notice the selection for the Body Site specific option is now No. When it is No the Subjective findings selections do not appear. When setting an Assessment up you can choose if the text box will appear with the Maitland Keyboard or not.
Previous Medical History (PMH) Template
The PMH template will show such information as previous injuries/surgeries, prescriptions, vaccinations and any physical activities the patient currently participates in. Below shows a PMH template in edit mode within the Clinical Templates. Notice the left hand side of the window shows different options that can be added to the template. These can be lookups, date/time selections and tables.
The below image shows the PMH template from the case. The Non-Prescription field is linked to a drop down with pre-populated information. The Vaccination and Physical Activities tables can be populated using a drop down and choosing dates and times.
Like the Summary template you can create multiple PMH templates but only one can be active. The current active template will have an orange Default box beside the name. To make another template default press the Make Default option.