Reference

Guide | Reference

6  Documentation Templates

Purpose. Provide consistent, time-scaled note structures that map to the core workflow. Keep documentation aligned with domains, specifiers, and formulation without overreach.

6.1 Template Set

• 1-Minute Note: minimal structure for quick capture and continuity.
• 5-Minute Note: standard visit note with brief formulation and monitoring.
• Comprehensive Note: full assessment and formulation for complex cases.
• Recording Format: compact diagnostic line for handoffs or summaries.

6.2 When to Use Which

• 1-Minute Note: follow-up visits, stable presentations, time-constrained settings.
• 5-Minute Note: new evaluations or significant changes.
• Comprehensive Note: initial workups, complex presentations, medico-legal contexts.

6.3 Required vs Optional Fields

• Required: presenting problem, safety screen, domain ratings, specifiers, documentation snippet.
• Optional: prototype tags, differential list, measurement plan, uncertainty notes.

6.4 Local Requirements

• Templates are meant to be adapted to local policy, billing, and legal needs.
• Add institutional sections as needed, but keep the core workflow intact.