Built-in note formats
Choose a format before you record, and Notermed drafts the visit into its sections. You review the draft, edit what you need, and sign. Nothing becomes part of the record until you do.
Each format lists its sections in order and what each one captures. Your clinic can also build its own formats in the app.
and 2 more sections
Asthma return visit per GINA stepwise management.
Interval History · Asthma Triggers · Inhaler Technique & Adherence · Medications …
7 sectionsCOPD return visit per GOLD 2024 guidelines.
Interval History · Spirometry / Pulmonary Function · Oxygen Therapy · Medications …
7 sectionsSleep apnea / CPAP therapy review per AASM guidelines.
Interval History · Device Data · Medications · Physical Examination …
6 sectionsPulmonary, Critical Care & Sleep Medicine encounter note.
Chief Complaint (CC) · History of Present Illness (HPI) · Past Medical History (PMHx) · Past Surgical History (PSHx) …
14 sectionsEveryday visit note (Subjective, Objective, Assessment, Plan).
Subjective · Objective · Assessment · Plan
4 sectionsComprehensive new-patient workup.
History of Present Illness · Past Medical History · Review of Systems (ROS) · Physical Examination …
7 sectionsReturn visit: interval history and updated plan.
Interval History · Current Symptoms / Response to Treatment · Medications · Focused Review of Systems …
7 sectionsSpecialist consultation for a referred patient.
Reason for Consultation · History of Present Illness · Past Medical & Surgical History · Review of Systems …
8 sectionsMinor office procedure or bedside intervention.
Procedure · Indication · Consent · Operator & Assistant …
9 sectionsFormal referral letter to another provider or specialist.
RE · Reason for Referral · Clinical Summary · Specific Request …
5 sectionsDetailed consultation letter back to the referring provider.
RE · Thank You for Referring This Patient · History · Examination …
7 sectionsInpatient or ED discharge with diagnoses, treatment, and plan.
Admission Details · Presenting Complaint · Hospital Course · Diagnoses …
8 sectionsRoutine well-child preventive visit.
Visit Type & Age · Interval History & Parental Concerns · Feeding & Nutrition · Elimination …
12 sectionsPediatric sick visit or general consult.
Presenting Complaint · History of Present Illness · Past Medical History · Family & Social History …
8 sectionsPediatric return visit for a known condition.
Interval History · Current Symptoms · Medications · Physical Examination …
6 sectionsPsychiatric or mental health assessment and plan.
Presenting Complaint · History of Present Illness · Psychiatric History · Medical History …
11 sectionsRheumatology visit note, drafted only from what was said.
Chief Complaint · History of Present Illness · Past Medical History · Medications …
12 sectionsEndocrinology, Diabetes & Metabolism encounter note.
Chief Complaint (CC) · History of Present Illness (HPI) · Past Medical History (PMHx) · Past Surgical History (PSHx) …
14 sectionsCardiology encounter note (ischemic, heart failure, arrhythmia).
Chief Complaint (CC) · History of Present Illness (HPI) · Past Medical History (PMHx) · Past Surgical History (PSHx) …
14 sectionsDermatology visit note with lesion morphology and distribution.
Chief Complaint · History of Present Illness · Past Medical History · Medications …
11 sectionsObstetrics & gynecology visit note (GYN problem or prenatal).
Chief Complaint · History of Present Illness · Obstetric History · Gynecologic History …
13 sectionsThese apply from your first free session, on every plan, whichever of these formats you write in. The technical detail is on the security and HIPAA page.
We sign a Business Associate Agreement with your clinic before any patient data is processed.
Patient data is stored and processed only on servers in the United States.
Recordings, transcripts and notes are encrypted in transit and at rest.
Patient conversations are never used to train AI models.
Every note is a draft until the clinician reviews it and signs it.
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
Bring a consultation and the format you would normally write it in. We will walk through the draft with you, and tell you plainly if Notermed is not a fit yet.