Creating a New Global Template in iClinic

1. Introduction

This guide provides a detailed, step-by-step process for creating and customizing global templates in iClinic. It covers accessing settings, configuring clinical sections, adding ICD/CPT codes, and managing prescription templates.

2. Accessing Global Template Settings

1. Log In: Sign in to your iClinic account.
2. Navigate to Settings: 
   • Click on the Settings Icon.
   • Select EMR from the menu.
   • Click on Global Templates.

3. Creating or Editing a Global Template

1. Create New Template: 
   • Click the New button at the top of the screen to start a new template.
2. Edit Existing Template: 
   • Use the Select Template dropdown to choose a pre-made template.
   • Click Apply to start editing.

4. Configuring Review of Systems (ROS)

1. Select Systems: 
   • Check the boxes next to the systems you want to include.
2. Set Default Status: 
   • By default, systems are marked as Normal.
   • To mark as Abnormal, check the corresponding box and select appropriate symptoms.
3. Copy to History of Present Illness (HPI): 
   • Click Copy to HPI to transfer ROS selections to HPI.
4. Restore Defaults: 
   • Click Restore to Default to revert changes.

5. Configuring Chief Complaint and HPI

1. Chief Complaint: 
   • Free-type relevant information or select from existing templates using the dropdown.
2. Custom Selectable Fields: 
   • Click the square icon to add custom choices.
   • Enter options, click Add for each, and use Modify for edits.
   • Set a default option with Set as Selected Value.
   • Allow multiple selections if needed.
3. Organizing Choices: 
   • Use the up/down arrows to rearrange options.
4. Saving: 
   • Click Insert to finalize and add to the template.

6. Adding Keywords

1. Insert Keywords: 
   • Click the minus symbol to access the keyword list.
   • Select keywords, review descriptions, and click Apply.
   • Place keywords in contextually appropriate locations.

7. Configuring Physical Exam Details

1. Standard Exam Sections: 
   • Choose Normal, Not Exam, or Abnormal.
   • Customize descriptions for abnormal findings.
2. User-Defined Areas: 
   • Access Settings > EMR > Office Visit > Customize Physical Exam Detail.
   • Rename user-defined areas and adjust default descriptions.
3. Ordering Sections: 
   • Highlight sections and use arrows to rearrange.
4. Additional Notes: 
   • Use the Others section for any extra details.

8. Adding ICD and CPT Codes

1. Add ICD Codes: 
   • Click Add ICD.
   • Search by code or description and click Go.
   • Avoid gray (non-HIPAA compliant) codes.
   • Double-click white codes to add.
2. Add CPT Codes: 
   • Search by name or code and click Search.
   • Double-click to add to the template.

9. Assessment, Plan, and Procedures

1. Link to ICD Codes: 
   • Each ICD code generates a corresponding section for notes.
2. Add Notes and Procedures: 
   • Use square icons to insert custom selectable areas.
   • Add additional notes in the Other section.

10. Adding Prescriptions

1. New Prescription: 
   • Click New RX.
   • Switch to Database to access all medications.
   • Search for the medication and double-click to add.
2. Configure Prescription Details: 
   • Choose a Recommended SIG.
   • Fill out quantity and qualifiers.
   • Click Save RX.
3. Custom SIGs: 
   • Click Edit under SIG to create custom instructions.
   • Complete dosage details and click Save RX.

11. Finalizing the Global Template

1. Name the Template: 
   • Enter a name and optional description at the top.
2. Set Access Permissions: 
   • Check Private if only you should access it.
   • Leave unchecked to share with other users.
3. Save the Template: 
   • Click Save to finalize.

12. Best Practices

• Keep Templates Updated: Regularly review and adjust templates based on clinical workflows.
• Use Keywords Efficiently: Apply keywords to generalize templates for broader use.
• Organize Information Clearly: Structure sections logically for easy navigation during office visits.

13. Troubleshooting Tips

• Missing Sections: Ensure the correct template is selected under Settings > EMR.
• Template Not Saving: Check for incomplete required fields.
• ICD/CPT Code Errors: Verify codes are current and HIPAA-compliant.

14. Support Resources

• In-App Help: Utilize iClinic’s help feature for guidance.
• Technical Support: Contact support for technical issues.
• Clinical Team: Consult with clinical staff for template optimization.

This guide ensures effective creation and management of global templates, enhancing documentation efficiency in iClinic.