Note templates and sections

Available templates and their sections

Notes generated by Nabla Core API follow different templates. Each template has a set of possible sections. Generating a note requires specifying a template, the generated note will then only contain sections relevant for the specified template.

Following is the list of all supported templates and their sections.

Note template	Remarks	Exhaustive sections list
GENERIC_MULTIPLE_SECTIONS	Recommended for general medicine.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_ILLNESS, PAST_MEDICAL_HISTORY, PAST_SURGICAL_HISTORY, PAST_OBSTETRIC_HISTORY, FAMILY_HISTORY, SOCIAL_HISTORY, ALLERGIES, CURRENT_MEDICATIONS, IMMUNIZATIONS, VITALS, LAB_RESULTS, IMAGING_RESULTS, PHYSICAL_EXAM, ASSESSMENT, PLAN, PRESCRIPTION, APPOINTMENTS.
GENERIC_MULTIPLE_SECTIONS_AP_MERGED	Alternative version of GENERIC_MULTIPLE_SECTIONS with the only notable change of having a single section for both Assessment and Plan. Only available in English.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_ILLNESS, PAST_MEDICAL_HISTORY, PAST_SURGICAL_HISTORY, PAST_OBSTETRIC_HISTORY, FAMILY_HISTORY, SOCIAL_HISTORY, ALLERGIES, CURRENT_MEDICATIONS, IMMUNIZATIONS, VITALS, LAB_RESULTS, IMAGING_RESULTS, PHYSICAL_EXAM, ASSESSMENT_AND_PLAN, PRESCRIPTION, APPOINTMENTS.
GENERIC_SOAP	Follows the Subjective, Objective, Assessment and Plan format.	SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN.
CARDIOLOGY_MULTIPLE_SECTIONS	Recommended for cardiology.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_ILLNESS, CARDIOVASCULAR_RISK_FACTORS, FAMILY_HISTORY, ALLERGIES, PAST_OBSTETRIC_HISTORY, PAST_SURGICAL_HISTORY, PAST_MEDICAL_HISTORY, SOCIAL_HISTORY, CURRENT_MEDICATIONS, VITALS, IMMUNIZATIONS, PHYSICAL_EXAM, LAB_RESULTS, IMAGING_RESULTS, ASSESSMENT, PLAN, PRESCRIPTION, APPOINTMENTS.
PSYCHIATRY_MULTIPLE_SECTIONS	Recommended for mental health care.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_ILLNESS, FAMILY_HISTORY, ALLERGIES, PAST_OBSTETRIC_HISTORY, PAST_SURGICAL_HISTORY, PAST_MEDICAL_HISTORY, SOCIAL_HISTORY, CURRENT_MEDICATIONS, VITALS, IMMUNIZATIONS, PHYSICAL_EXAM, LAB_RESULTS, IMAGING_RESULTS, ASSESSMENT, MENTAL_HEALTH_EXAM, PLAN, PRESCRIPTION, APPOINTMENTS.
DIET_MULTIPLE_SECTIONS	Recommended for nutritional guidance.	LIFESTYLE, PAST_MEDICAL_HISTORY, CHIEF_COMPLAINT, VITALS, FOOD_HABITS, OBJECTIVES_AND_ADVICE, APPOINTMENTS.
PSYCHOLOGY_MULTIPLE_SECTIONS	Recommended for psychological care.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_COMPLAINT, MENTAL_HEALTH_HISTORY, SOCIAL_HISTORY, MENTAL_HEALTH_EXAM, ASSESSMENT, PLAN, APPOINTMENTS.
WCC_MULTIPLE_SECTIONS	Recommended for Well Child Care visits. Includes a WCC-specific section with sub-sections: Behavioural and social Language and communication Cognitive Movement and physical development Diet & pooping Only available in English.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_ILLNESS, WELL_CHILD_CARE, PAST_MEDICAL_HISTORY, PAST_SURGICAL_HISTORY, PAST_OBSTETRIC_HISTORY, FAMILY_HISTORY, SOCIAL_HISTORY, ALLERGIES, CURRENT_MEDICATIONS, IMMUNIZATIONS, VITALS, LAB_RESULTS, IMAGING_RESULTS, PHYSICAL_EXAM, ASSESSMENT, PLAN, PRESCRIPTION, APPOINTMENTS.
WCC_SOAP	Recommended for Well Child Care visits. Follows the SOAP format. Includes a WCC-specific section with sub-sections: Behavioural and social Language and communication Cognitive Movement and physical development Diet & pooping Only available in English.	SUBJECTIVE, WELL_CHILD_CARE, OBJECTIVE, ASSESSMENT, PLAN.
EMERGENCY_MULTIPLE_SECTIONS	Recommended for emergency medicine providers. Only available in English.	CHIEF_COMPLAINT, HISTORY_OF_PRESENT_ILLNESS, PAST_MEDICAL_HISTORY, PAST_SURGICAL_HISTORY, PAST_OBSTETRIC_HISTORY, FAMILY_HISTORY, SOCIAL_HISTORY, ALLERGIES, CURRENT_MEDICATIONS, IMMUNIZATIONS, VITALS, LAB_RESULTS, IMAGING_RESULTS, PHYSICAL_EXAM, ASSESSMENT, PLAN, PRESCRIPTION, APPOINTMENTS.
EMERGENCY_SOAP	Recommended for emergency medicine providers. Follows the SOAP format. Only available in English.	SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN.

Example note

Here are few examples of clinical notes generated using different templates.

• Using GENERAL_MEDICINE template:

{
  "note": {
    "title": "Headache and Back Pain",
    "sections": [
      {
        "key": "CHIEF_COMPLAINT",
        "title": "Chief complaint",
        "text": "Severe headache. Back pain. Broken ankle from last week."
      },
      {
        "key": "HISTORY_OF_PRESENT_ILLNESS",
        "title": "History of present illness",
        "text": "The patient presented today with a strong headache and severe back pain. The back pain is particularly intense and the patient also mentioned a recent ankle fracture that occurred last week. The patient expressed a desire to see a therapist and requested prescriptions for pain management, specifically mentioning Advil, Ibuprofen, or Augmentin. The patient's current weight is 72 kilograms and height is 1.80 meters."
      },
      {
        "key": "VITALS",
        "title": "Vitals",
        "text": "Height: 1.80m. Weight: 72kg."
      },
      {
        "key": "PLAN",
        "title": "Plan",
        "text": "Schedule appointment with a therapist."
      },
      {
        "key": "PRESCRIPTION",
        "title": "Prescription",
        "text": "Ibuprofen 400mg, take every 6-8 hours as needed for pain."
      }
    ]
  }
}

• Using DIET template:

{
  "note": {
    "title": "Weight Management and Lifestyle Plan",
    "sections": [
      {
        "key": "LIFESTYLE",
        "title": "Lifestyle",
        "text": "Sedentary professional activity, no regular physical activities."
      },
      {
        "key": "PAST_MEDICAL_HISTORY",
        "title": "Medical history",
        "text": "Allergic to peanuts, experiencing regular headaches, family history of diabetes."
      },
      {
        "key": "CHIEF_COMPLAINT",
        "title": "Reason for visit and goals",
        "text": "To improve overall health and manage weight."
      },
      {
        "key": "VITALS",
        "title": "Vitals",
        "text": "Weight is 110 kg, height and BMI not mentioned."
      },
      {
        "key": "OBJECTIVES_AND_ADVICE",
        "title": "Objectives and advice",
        "text": "- Start incorporating physical activity into daily routine.\n- Avoid peanuts and other allergens.\n- Reduce intake of processed and high-fat foods.\n- Increase intake of fiber, vegetables, and lean proteins."
      },
      {
        "key": "APPOINTMENTS",
        "title": "Appointment",
        "text": "Next appointment in 4 weeks."
      }
    ]
  }
}