Guide

Guide | Reference

8  Documentation Templates (Overview)

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

Full templates live in the Clean Reference and the repo; this section summarizes them for orientation.

8.1 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.

8.2 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.

8.3 Required vs Optional Fields

• Required: presenting problem, safety screen, domain ratings, specifiers, brief summary line.
• Optional: prototype tags, differential list, monitoring plan, uncertainty notes.

8.4 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.