{
    "section": "plan",
    "templateSet": "Urinary Incontinence",
    "templates": [
        {
            "text": "Ordered Labs",
            "template": "Ordered Labs{children}",
            "children": [
                {
                    "text": "Blood Chemistry\/Hematology",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Beta-hCG, qualitative, serum",
                            "template": "Beta-hCG, qualitative, serum"
                        },
                        {
                            "text": "CBC",
                            "template": "CBC"
                        },
                        {
                            "text": "Glucose, fingerstick",
                            "template": "Glucose, fingerstick"
                        },
                        {
                            "text": "Glucose, fasting, plasma",
                            "template": "Glucose, fasting, plasma"
                        },
                        {
                            "text": "Hemoglobin A1c (HbA1c), blood",
                            "template": "Hemoglobin A1c (HbA1c), blood"
                        },
                        {
                            "text": "Metabolic panel, basic (BMP), serum",
                            "template": "Metabolic panel, basic (BMP), serum"
                        },
                        {
                            "text": "Metabolic panel, comprehensive (CMP), serum",
                            "template": "Metabolic panel, comprehensive (CMP), serum"
                        }
                    ]
                },
                {
                    "text": "Urine tests",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Beta-hCG, qualitative, urine",
                            "template": "Beta-hCG, qualitative, urine"
                        },
                        {
                            "text": "Culture, urine, bacterial",
                            "template": "Culture, urine, bacterial"
                        },
                        {
                            "text": "Urinalysis, complete (with micro)",
                            "template": "Urinalysis, complete (with micro)"
                        },
                        {
                            "text": "Urine dipstick for nitrites and leukocyte esterase",
                            "template": "Urine dipstick for nitrites and leukocyte esterase"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Ordered Imaging",
            "template": "Ordered Imaging{children}",
            "children": [
                {
                    "text": "CT",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "CT abdomen and pelvis w\/ contrast",
                            "template": "CT abdomen and pelvis w\/ contrast"
                        },
                        {
                            "text": "CT abdomen and pelvis w\/o contrast",
                            "template": "CT abdomen and pelvis w\/o contrast"
                        }
                    ]
                },
                {
                    "text": "MRI",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "MRI pelvis w\/ contrast",
                            "template": "MRI pelvis w\/ contrast"
                        },
                        {
                            "text": "MRI pelvis w\/o contrast",
                            "template": "MRI pelvis w\/o contrast"
                        }
                    ]
                },
                {
                    "text": "Plain Films",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "X-ray abdomen (KUB)",
                            "template": "X-ray abdomen (KUB)"
                        }
                    ]
                },
                {
                    "text": "Ultrasound",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "US bladder",
                            "template": "US bladder"
                        },
                        {
                            "text": "US pelvis",
                            "template": "US pelvis"
                        },
                        {
                            "text": "US renal",
                            "template": "US renal"
                        },
                        {
                            "text": "US urethra",
                            "template": "US urethra"
                        }
                    ]
                },
                {
                    "text": "Other",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Intravenous pyelogram (IVP)",
                            "template": "Intravenous pyelogram (IVP)"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Ordered Medications",
            "template": "Ordered Medications{children}",
            "children": [
                {
                    "text": "Antispasmodics",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Detrol 2 mg tab",
                            "template": "Detrol 2 mg tab"
                        },
                        {
                            "text": "Detrol LA 4 mg ER cap",
                            "template": "Detrol LA 4 mg ER cap"
                        },
                        {
                            "text": "Oxybutynin 5 mg tab",
                            "template": "Oxybutynin 5 mg tab"
                        },
                        {
                            "text": "Oxybutynin 5 mg ER tab",
                            "template": "Oxybutynin 5 mg ER tab"
                        },
                        {
                            "text": "Toviaz 4 mg ER tab",
                            "template": "Toviaz 4 mg ER tab"
                        },
                        {
                            "text": "Vesicare 5 mg tab",
                            "template": "Vesicare 5 mg tab"
                        }
                    ]
                },
                {
                    "text": "Tricyclics",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Amitriptyline 25 mg tab",
                            "template": "Amitriptyline 25 mg tab"
                        },
                        {
                            "text": "Desipramine 25 mg tab",
                            "template": "Desipramine 25 mg tab"
                        },
                        {
                            "text": "Doxepin 25 mg cap",
                            "template": "Doxepin 25 mg cap"
                        },
                        {
                            "text": "Imipramine 25 mg tab",
                            "template": "Imipramine 25 mg tab"
                        },
                        {
                            "text": "Nortriptyline 25 mg cap",
                            "template": "Nortriptyline 25 mg cap"
                        }
                    ]
                },
                {
                    "text": "Serotonin norepinephrine reuptake inhibitors (SNRIs)",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Cymbalta 60 mg DR cap",
                            "template": "Cymbalta 60 mg DR cap"
                        }
                    ]
                },
                {
                    "text": "Estrogen supplementation",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Estrace vaginal cream",
                            "template": "Estrace vaginal cream"
                        },
                        {
                            "text": "Estring 2 mg ring",
                            "template": "Estring 2 mg ring"
                        },
                        {
                            "text": "EstroGel 0.06% gel",
                            "template": "EstroGel 0.06% gel"
                        }
                    ]
                },
                {
                    "text": "Antibiotics",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Cipro XR 500 mg ER tab",
                            "template": "Cipro XR 500 mg ER tab"
                        },
                        {
                            "text": "Ciprofloxacin 250 mg tab",
                            "template": "Ciprofloxacin 250 mg tab"
                        },
                        {
                            "text": "Levaquin 250 mg tab",
                            "template": "Levaquin 250 mg tab"
                        },
                        {
                            "text": "Nitrofurantoin 100 mg ER cap",
                            "template": "Nitrofurantoin 100 mg ER cap"
                        },
                        {
                            "text": "Ofloxacin 200 mg tab",
                            "template": "Ofloxacin 200 mg tab"
                        },
                        {
                            "text": "Trimethoprim\/Sulfamethoxazole 160 mg\/800 mg tab",
                            "template": "Trimethoprim\/Sulfamethoxazole 160 mg\/800 mg tab"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Ordered Supplies, Equipment",
            "template": "Ordered Supplies, Equipment{children}",
            "children": [
                {
                    "text": "Supplies",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Fem Soft",
                            "template": "Fem Soft"
                        },
                        {
                            "text": "Use vaginal pessaries",
                            "template": "Use vaginal pessaries"
                        },
                        {
                            "text": "Incontinence pads",
                            "template": "Incontinence pads"
                        },
                        {
                            "text": "Vaginal pessary, non-rubber",
                            "template": "Vaginal pessary, non-rubber"
                        },
                        {
                            "text": "Vaginal pessary, rubber",
                            "template": "Vaginal pessary, rubber"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Ordered Procedures",
            "template": "Ordered Procedures{children}",
            "children": [
                {
                    "text": "Procedures",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "EMG",
                            "template": "EMG"
                        },
                        {
                            "text": "Cystoscopy",
                            "template": "Cystoscopy"
                        },
                        {
                            "text": "Post-void residual by catheter",
                            "template": "Post-void residual by catheter"
                        },
                        {
                            "text": "Post-void residual by ultrasound",
                            "template": "Post-void residual by ultrasound"
                        },
                        {
                            "text": "InTone therapy",
                            "template": "InTone therapy"
                        },
                        {
                            "text": "Interstim PNE",
                            "template": "Interstim PNE"
                        },
                        {
                            "text": "Interstim permanent",
                            "template": "Interstim permanent"
                        },
                        {
                            "text": "Intravesical Botox injection",
                            "template": "Intravesical Botox injection"
                        },
                        {
                            "text": "Urethral bulking procedure",
                            "template": "Urethral bulking procedure"
                        },
                        {
                            "text": "Urethroscopy",
                            "template": "Urethroscopy"
                        },
                        {
                            "text": "Urodynamic testing",
                            "template": "Urodynamic testing"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Patient Instructions",
            "template": "Patient provided with the following instructions:{children}",
            "children": [
                {
                    "text": "Patient provided with the following instructions",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Bladder instruction training given (prompted\/timed voiding)",
                            "template": "Bladder instruction training given (prompted\/timed voiding)"
                        },
                        {
                            "text": "Keep a bladder diary",
                            "template": "Keep a bladder diary"
                        },
                        {
                            "text": "Voiding diary given with instructions for completion",
                            "template": "Voiding diary given with instructions for completion"
                        },
                        {
                            "text": "Lose weight to help alleviate sx",
                            "template": "Lose weight to help alleviate sx"
                        },
                        {
                            "text": "Eliminate\/reduce caffeine, carbonated beverages, highly acidic\/spicy foods",
                            "template": "Eliminate\/reduce caffeine, carbonated beverages, highly acidic\/spicy foods"
                        },
                        {
                            "text": "Restrict fluids, especially after 6 p.m.",
                            "template": "Restrict fluids, especially after 6 p.m."
                        },
                        {
                            "text": "Quit smoking",
                            "template": "Quit smoking"
                        },
                        {
                            "text": "Pelvic floor muscle strengthening techniques given (Kegel exercises for women)\n                            ",
                            "template": "Pelvic floor muscle strengthening techniques given (Kegel exercises for women)\n                            "
                        },
                        {
                            "text": "Wear incontinence pad (to assess for incontinence that cannot be reproduced on\n                                exam)\n                            ",
                            "template": "Wear incontinence pad (to assess for incontinence that cannot be reproduced on\n                                exam)\n                            "
                        },
                        {
                            "text": "Learn to recognize and manage constipation sx",
                            "template": "Learn to recognize and manage constipation sx"
                        },
                        {
                            "text": "Use vaginal pessaries for short-term symptom control",
                            "template": "Use vaginal pessaries for short-term symptom control"
                        },
                        {
                            "text": "Information\/Educational handouts",
                            "template": "Information\/Educational handouts"
                        },
                        {
                            "text": "InTone Therapy information",
                            "template": "InTone Therapy information"
                        },
                        {
                            "text": "Stress Incontinence progressive treatment",
                            "template": "Stress Incontinence progressive treatment"
                        },
                        {
                            "text": "Urgency incontinence progressive treatment options",
                            "template": "Urgency incontinence progressive treatment options"
                        },
                        {
                            "text": "Informed consent stress incontinence surgery",
                            "template": "Informed consent stress incontinence surgery"
                        }
                    ]
                }
            ]
        },
        {
            "text": "Follow-up, Referrals",
            "template": "Follow-up, Referrals{children}",
            "children": [
                {
                    "text": "Return visits",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Return visit as needed",
                            "template": "Return visit as needed"
                        },
                        {
                            "text": "Return visit in 1 week",
                            "template": "Return visit in 1 week"
                        },
                        {
                            "text": "Return visit in 2 weeks",
                            "template": "Return visit in 2 weeks"
                        },
                        {
                            "text": "Return visit in 1 month",
                            "template": "Return visit in 1 month"
                        },
                        {
                            "text": "Return visit in 2 months",
                            "template": "Return visit in 2 months"
                        },
                        {
                            "text": "Return visit in 3 months",
                            "template": "Return visit in 3 months"
                        },
                        {
                            "text": "Return visit in 6 months",
                            "template": "Return visit in 6 months"
                        },
                        {
                            "text": "Return visit in 1 year",
                            "template": "Return visit in 1 year"
                        },
                        {
                            "text": "Return for InTone therapy",
                            "template": "Return for InTone therapy"
                        }
                    ]
                },
                {
                    "text": "Admit to ER\/inpatient care",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Admit to ER",
                            "template": "Admit to ER"
                        },
                        {
                            "text": "Admit to hospital",
                            "template": "Admit to hospital"
                        }
                    ]
                },
                {
                    "text": "Referrals",
                    "template": "{children}",
                    "children": [
                        {
                            "text": "Refer to Urology",
                            "template": "Refer to Urology"
                        },
                        {
                            "text": "Refer to smoking cessation program",
                            "template": "Refer to smoking cessation program"
                        },
                        {
                            "text": "Refer pelvic floor physical therapy",
                            "template": "Refer pelvic floor physical therapy"
                        },
                        {
                            "text": "Referred for InTone therapy",
                            "template": "Referred for InTone therapy"
                        }
                    ]
                }
            ]
        }
    ]
}