1. Margins desired, measured from the top, bottom, left and right sides of page
2. Header information
a. Include logos or photos
3. Footer information
4. Format desired. Please see our standard templates for examples.
5. Specific data collection prompters desired
a. Specific questions with check boxes listed in the HPI
b. Listing only the names of organ systems with space to write in additional data
c. Providing check boxes for “within normal limits” and “see HPI” options by each organ system
d. Providing itemized lists of prompter questions within each organ system, detailed to your specifications.
6. Past Medical History
a. Blank box
b. Prompters (i.e., CHF, Diabetes, CAD) with check boxes
c. Specify prompters
8. Impression and Plan
9. Specific frequent advice to be included or Quality Improvement measures, etc.
10. Intended users, and any specific additions needed (i.e., additional signature line)
a. Primary care physicians
b. Specialist physicians (please include specialty)
d. Physician Assistants
f. Respiratory Therapists
11.Type of user license requested (i.e., individual practitioner, 3-5 practitioners, unlimited practitioners)