Encounter Note Template CodeSystem Code system

Canonical	../CodeSystem/encounter-note-template
Status	draft · 1.26.0
Content	complete
Source	FSH · JSON

The templates the encounter-note editor can open a note from -- the starting structure a provider picked, carried on the note in the composition-note-setup extension so a draft reopens the way it was left.

This is not CodeSystem/nexus-template. That system is the coding view of the stored template registry: its codes are the per-tenant slugs of template List resources, its content is not-present because membership is discovered by search, and it rides meta.tag on a letter to say which stored template that letter was composed from. This system names the fixed catalogue of note structures compiled into the application -- fourteen codes shipped with the software, with no List behind any of them. Merging them would claim a completeness nexus-template explicitly disclaims, and because both value spaces are kebab-case slugs, a tenant-authored letter template could collide with a note template of the same name.

A template is structure only. It contributes an ordered run of headings and the empty areas beneath them; no template pre-writes clinical text. The code therefore says which headings a note started with and nothing about what they ended up saying.

The code records what the note was opened from, not what it contains. A provider may switch templates mid-note, delete every heading the template gave, or type their own. The authoritative structure is always Composition.section; this code exists so a draft can be reopened on the same footing.

Content is complete: this system lists all of its own codes. The binding from composition-note-setup is extensible, so a template this guide has not named yet is still conformant on the wire.

Code	Display	Definition
blank-note	Blank note	Somewhere to write, with no heading at all. Every visit type offers this one, and it is always last in the list.
focused-soap	Focused SOAP	Visit agenda, subjective, vitals, objective, assessment and plan, patient instructions. The default for a same-day urgent visit.
antenatal-follow-up	Antenatal follow-up visit	A routine visit in an established pregnancy: agenda, subjective, vitals, antenatal measures, assessment and plan, patient instructions.
first-prenatal-visit	First prenatal visit	The booking visit: agenda, obstetric and medical history, vitals, antenatal measures, physical exam, assessment and plan, patient instructions.
third-trimester-check	Third-trimester check	Agenda, subjective, vitals, antenatal measures, assessment and plan, and a birth plan section in place of the usual instructions.
adult-periodic-health	Adult periodic health	The full periodic health review: agenda, history, vitals, review of systems, physical exam, screening and prevention, assessment and plan, patient instructions.
preventive-health	Preventive health	A shorter prevention-focused visit: agenda, vitals, screening and prevention, assessment and plan, patient instructions.
diabetes-review	Diabetes review	Agenda, subjective, vitals, a structured diabetes review area, assessment and plan, patient instructions.
diabetes-flow-sheet	Diabetes flow sheet	The measurement-led variant: agenda, vitals, a structured diabetes review area, assessment and plan. No free subjective section.
brief-phone-note	Brief phone note	Reason for call, note, plan. The default for a telephone visit.
mental-health-assessment	Mental health assessment	The initial assessment: agenda, history and presenting concerns, risk assessment, mental status exam, assessment and plan, safety plan and instructions.
mental-health-follow-up	Mental health follow-up	Agenda, subjective, risk assessment, assessment and plan, patient instructions.
procedure-note	Procedure note	Indication, consent, a structured procedure details area, procedure narrative, assessment and plan, aftercare instructions.
form-supporting-note	Form-supporting note	The note written to support completing a form: form requested, relevant history, findings, assessment and plan.