From any patient's visit note, select Note Templates in the top navigation bar, next to Patient List.

Faster option — duplicate instead of starting blank: open any existing template and select Duplicate Template in the top right. Click into the new copy's title to rename it — this is the quick way to build a variant of something you already have (for example, cloning "Annual Wellness Exam" into "Medicare Annual Wellness" and only adjusting what's actually different between the two).

Select Review of Systems or Physical Examination in the Note Sections list to open that section's editor. Each one gives you two tabs: Standard Template and With Inline Instructions.

On the Standard Template tab, CarePilot explains how it works right on the screen:

Below that explainer is the actual baseline text box — this is the part you write and edit directly. As a real example, here's the Review of Systems baseline currently sitting on the Annual Wellness Exam template:

General: No weight loss or gain, no fever, no fatigue.

Skin: No rashes, lumps, itching, dryness, or color changes. No abnormal hair or nail growth.

Head: No headaches, dizziness, or syncope. No history of trauma.

Eyes: No vision changes, pain, redness, or discharge.

Ears: No hearing loss, tinnitus, pain, infections, or discharge. Nose: No discharge, congestion, epistaxis, or sinus pain.

Throat/Mouth: No sore throat, dental issues, hoarseness, dysphagia, or changes in taste.

Cardiovascular: No chest pain, SOB, palpitations, ankle swelling. Respiratory: No cough, wheezing, SOB. Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, constipation, GERD, normal appetite.

Genitourinary: No incontinence, difficulty urinating, hematuria, dysuria, or increased frequency.

Musculoskeletal: No muscle aches, muscle weakness, joint pain, back pain, neck pain, difficulty walking. Neurologic: No numbness, weakness, seizures, loss of consciousness, dizziness, headaches, tremors, or gait dysfunction.

Psychiatric: No anxiety, depression, insomnia, alcohol abuse, suicidal thoughts, mood swings or delirium.

And the Physical Examination baseline on that same template:

General Appearance: The patient is alert and oriented x3, well-nourished and well-groomed, in no acute distress.

HEENT:

Head: Normocephalic, atraumatic.

Eyes: PERRLA, EOMI, no conjunctival injection.

Ears: TMs intact bilaterally, no erythema or effusion.

Nose: No discharge or congestion.

Throat: Oropharynx clear, no erythema or exudates.

Neck: Supple, full ROM, no lymphadenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops. No JVD or peripheral edema.

Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Normal respiratory effort.

Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly. Normal bowel sounds.

Musculoskeletal: Full ROM in all joints. No swelling, tenderness, or deformities. Skin: No rashes, lesions, or abnormal pigmentation.

Neurological: CN II-XII intact. DTRs 2+ and symmetric. Normal gait and station. No focal deficits.

Psychiatric: Appropriate affect and behavior. Normal thought process and content.

This is exactly the kind of "everything's normal" language you'd dictate if the visit turned up nothing abnormal — write your own version the same way, system by system. CarePilot loads this by default and only overwrites the lines where the transcript or your dictation says otherwise.

Below the baseline text box is an Additional Instructions field — optional, plain-language formatting or content guidance for this section specifically (the placeholder example CarePilot shows is "Use bullet points, include vital signs, avoid medical jargon").

For Review of Systems specifically, there's also an Append ROS to HPI section checkbox above the two tabs, if you'd rather fold ROS findings into the HPI narrative instead of keeping it as its own section.

Sections like History of Present Illness show a Learning Progress tracker (Step 0 of 3, etc.) — that's Learn Format: generate a note, edit that section to match your style, click Learn Format, and repeat 2–3 times until it's dialed in. Review of Systems and Physical Exam don't work that way — they use the Standard “Rigid” Template baseline described above instead. So it's expected that you'll see the Learning Progress tracker under HPI but not under ROS/PE — that's not a bug, it's just two different customization mechanisms for two different kinds of content.

Review how to Teach CarePilot your style.

If you're not sure what should go in a baseline, or want a hand drafting one, Amelia — the co-pilot panel on the right side of any visit — can help. She's there for exactly this kind of "I don't know where to start" moment, not just for in-visit note edits.

This article covers the mechanics: getting to Note Templates, creating one, and building out its Review of Systems and Physical Exam baseline. A follow-up covering pre-built starting points by specialty — using the templates already in this account, like Ortho - Shoulder and Behavior Health - Follow Up, as real examples — is coming next; we'll link it here once it's ready.

Questions? Reach out any time in the Help Center chat.