e-MedTools

Hospital H&P Medical Note Template

admin — Mon, 17 Nov 2008 03:32:25 +0000

The hospital history and physical (Hospital H&P) MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers who evaluate and treat patients in hospitals.

When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.

New Inpatient Evaluation (History and Physical) - Upload a Document to Scribd

New Inpatient Evaluation Date Allergies Medications MRN Chief complaint/Reason for consult History of present illness Start time Stop time Social History  Tobacco use ____ Packs x ____ Yrs  Quit Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems  >/= 2 Falls within past 12 months, OR 1 which resulted in injury 4  Alcohol use ______ Drinks per  day  week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day  Recreational drug use  Injectable  Inhalational  Ingestible  Prescription Drug Dependence  Narcotics  Benzodiazepines See HPI WNL  Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite  Eyes Vision changes, New pain, Scotomas  ENT/mouth Nose bleeds, dental caries, dental abscess, jaw pain  Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea  CV Chest pain, diaphoresis, ankle edema, PND, syncope, claudication symptoms  GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena  GU Change in urinary habits, hematuria, dysuria  Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling  Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun  Neuro Seizures, episodic or chronic muscle weakness  Endo Hair loss, polydipsia  Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes  Allergy/Immun Sinus probs, recurrent infections  Psych Mood changes, agitation, psychosis, delirium, dementia Occupational History Family Medical History  Asthma  Congestive Heart Failure  COPD  Coronary Artery Disease  Premature Onset  Diabetes  Malignancy  Neuromuscular weakness  Obstructive Sleep Apnea  Pancreatitis  Peripheral Artery Disease  Renal Dysfunction  Thyroid Disease Past Medical and Surgical History Asthma Hypertension  Pulmonary HypertensionSurgeries Autoimmune disease Malignancy  Renal Dysfunction Cerebral Artery Disease Chemotherapy Rheumatic fever Congenital heart defects Radiation exposure Seizure Disorder COPD Myocardial infarction Shunt Coronary Artery Disease Stent placement  Steroid use Diabetes Type 1 Type 2 Neuromuscular weakness Thrombotic Disease GERD Obstructive Sleep Apnea Thyroid Disease Heart Failure CPAP BiPAP  Valvular disorders Hepatitis Occupational exposures HIV/AIDS Peripheral Artery Disease  CABG  Cardiac Catheterization  Stress Test  ECHO  Mammogram  PapSmear  PFTs  Colonoscopy ©MB and RR 2006, 2007 Revised 16June07 New Inpatient Evaluation Vaccines Flu Pneum Vitals Weight Height Temperature BP Sitting BP Standing Pulse Sats CVP Cardiac Output Urine Output/24 hrs Urine Output/8 hrs BCG Tetanus Pertussis Varicella Exam Ventilator Settings Mode Rate Tidal Vol PEEP PS FiO2 PO2/FiO2 Plateau Pressure NonInvasive Ventilator (CPAP, BiPAP) Settings  Alert  Conjunctivae Pupils Discs ENT TM Pharynx Dentition  Nasal External ears  Hearing Neck  Exam  Thyroid Resp  Clear to auscultation  Clear to percussion Effort Normal to palpation CV  Auscultation  Palpation  Edema Carotids  Aorta Femoral pulses  Pedal pulses GI  Abdomen  No hepatosplenomegaly  No hernias  Rectum  Guaiac Breasts  Inspection Palpation GU  Scrotum  Penis  Prostate  Urethra Gyn  External  Bladder  Cervix  Uterus  Adnexa Lymph  Neck  Axilla  Groin  Other Musc  Gait  Digit  Inspection  ROM  Stability  Strength Skin  Inspection  Palpation Neuro  CN  DTR  Sensation  Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Psych  Affect  Insight  Memory General Eye Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Impression and Plan Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Data Reviewed  Past Medical History  Social History  Family Medical History  Allergy list  Medication list  Labs/Tests  ER Notes  Old Chart  EMS Note  ECG  Nursing Notes & Vitals log  Radiology studies Care coordinated with ER MD HCPOA PCP Case Management Social Worker Pharmacy Nutrition team Physical therapy Respiratory therapy Nursing staff ©MB and RR 2006, 2007 Carotid Dopplers, Neck CT Angiography, MR Angiography11 Pts with ischemic stroke or transient ischemic attack CT or MRI of head within 24 hrs of admission10 Pts with ischemic stroke or transient ischemic attack Hemoglobin A1c level1 ACE Inhibitor/ARB therapy5 Pts with heart failure + left ventricular dysfunction Aspirin within 24 hrs of admission for AMI 28 Beta-blocker therapy 29, 7,8 Pt with AMI, CAD + prior MI, and heart failure + left ventricular dysfunction DVT prophylaxis Intense glycemic control Stress ulcer prophylaxis Sedation vacation - daily Changing central lines Enteral/Parenteral feeds Flu vac prior to discharge Head of bed elevated > 30 deg at all times Pneum vac prior to discharge Physical therapy Pulmonary toilet - aggressive Speech therapy evaluation Hospice Consult Ethics Consult Smoking Cessation Counseling Provided Revised 16June07 New Inpatient Evaluation Signature  Patient has completed advanced health care directives47 CODE STATUS Patient is a FULL CODE HCPOA is DNAR DO NOT ATTEMPT RESUSCITATION ©MB and RR 2006, 2007 Revised 16June07

Template updated on 11/16/08

Template Features

E&M Documentation Template
Digital Health Record
Digital Signature Option
Reminders
- Follow Up
- Referral
- Labs
- Therapeutic options

Shopper Support

E & M Documentation Template

The hospital H&P MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new hospital patient evaluation or inpatient consult.

History
Click here to learn about History Documentation
- Chief complaint
- History of present illness
- Past medical and surgical history
- Social history
  - Risk factors for disease (occupational exposures, smoking, and others)
- Family history
- Review of systems
  - Yes/No checkboxes for clear and complete documentation
Examination
Click here to learn about Physical Exam Documentation
- When completed, represents a comprehensive (highest) level physical exam as defined in 1997 Guidelines.
- General Multisystem Exam
- Checkboxes for pertinent negatives and common positive findings
Medical Decision Making
Click here to learn about MDM Documentation
- Full page for adequate space with complex patients
- Easy Documentation with checkboxes
  - Review of labs, tests, imaging, old records
  - Coordination of care
  - Common diagnostic and therapeutic options
- Assessment and plan

Medical Documentation References and Resources

Digital Health Record

The hospital H&P MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes. This allows information to be typed in or pasted from other applications to fill out the template.

Filled hospital H&P MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.

To learn more about how MedicalTemplates can be used as a digital health record, click here.

Digital Signature Enabled

MedicalTemplates can be signed with a digital signature, instead of a handwritten signature, if the use of a digital signature is acceptable at your practice location. Adobe PDF digital signatures require the creation of a digital ID that is used to sign the PDF.To learn more about Adobe PDF digital signatures, click here.

Adobe Reader Required

MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader. With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.

Clinic H&P

admin — Mon, 17 Nov 2008 03:20:55 +0000

Clinic H&P Medical Note Template

The clinic history and physical (clinic H&P) MedicalTemplate is suitable for internal medicine physicians, family practice physicians, and other health care providers.

Clinic History and Physical MedicalTemplate - Upload a Document to Scribd

Ambulatory Evaluation Review of Systems Yes Constitution Fatigue Malaise Fever or chills Appetite changes Eyes Vision changes New pain Scotomas ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Urinary changes Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rashes Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Patient Name Chief complaint/Reason for consult No Patient DOB Referring MD History of Present Illness ‰Patient is Nonverbal. History obtained from ‰Family ‰Medical records Allergies and Medications ‰Allergy List reviewed Medications ‰No drug allergies ‰No food allergies ‰Medications reviewed Social History ‰Medications reconciled with Nursing Home or Hospital discharge Info œ46 Risk factors ‰Domestic violence ‰Tattoos ‰High risk sexual behavior ‰Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics ‰Benzodiazepines ‰Never Smoker ‰Chews tobacco ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit ‰Patient is unwilling to quit ‰Patient willing to consider quitting ‰Patient quit, but resumed smoking ‰Patient willing to quit within 1 month Patient has tried ‰Nicotine replacement ‰Buproprion or nortriptyline ‰Nicotine receptor blockade ‰Asthma ‰CHF ‰COPD ‰Coronary Artery Dis ‰Premature Onset ‰Malignancy, specify Family Medical History ‰Pancreatitis ‰Peripheral Artery Disease ‰Renal Dysfunction ‰Thrombotic disorder ‰Thyroid Disease Daily, occasional and ex-smokers are more likely to be hazardous drinkers 1 “drink” is equal to 12 oz. can of beer, 1.5 oz. liquor (80 proof) or 5 oz wine ‰Alcohol use _____ Drinks per ‰day ‰week Definitions of Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day Past Medical and Surgical History Allergy/Immunology Sinus problems Recurrent infections Psychologic Mood changes Agitation Psychosis ‰Asthma ‰Hypertension ‰Adrenal dysfunction ‰Inflammatory Bowel Disease ‰Arthritis ‰Irritable Bowel Syndrome ‰Cerebral Artery Dis ‰Myocardial Infarction ‰CHF ‰Neuromuscular weakness ‰COPD ‰Pancreatitis ‰Coronary Artery Dis ‰Peripheral Artery Disease ‰Cystic Fibrosis ‰Renal dysfunction ‰Diabetes ‰1 ‰2 ‰Thrombotic disease ‰GERD ‰Thyroid disease, hyper ‰Gout ‰Thyroid disease, hypo ‰Hepatic dysfunction ‰Seizure disorder ‰HIV/AIDS ‰Sleep Apnea ‰CPAP ‰BiPAP ‰Chemotherapy ‰Colonoscopy ‰ECHO/Stress test ‰Immunosuppressive therapy ‰Mammogram ‰Organ failure ‰PFTs ‰Pap Smear ‰Prior intubations ‰Radiation exposure ‰Sleep study ‰Steroid use, chronic ‰Strokes ‰CABG ‰Splenectomy ‰Organ transplant ‰Other Surgeries ‰Malignancy ‰Adrenal ‰Colon ‰Melanoma ‰Renal cell ‰Thyroid ‰Breast ‰Lung ‰Prostate ‰Testicular Vaccines ‰Flu ‰Pneumo ‰Tetanus ‰Papilloma ‰Varicella ‰Pertussis ‰Hepatitis ‰BCG ©MB and RR 2006-2008 Revised1Sep08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Ambulatory Evaluation Prior Diagnostic Data \____/ / \ ____ / ____ / ____ / \ \ \ Patient Name Exam Patient DOB ‰Checked box indicates findings are within normal limits OR stated abnormality is present % General ‰Alert Vitals T Prate ‰Reg ‰Irreg R BP Sats ‰ Conjunctivae ‰Pupils ‰Discs Eye ENT ‰TM ‰Pharynx ‰Dentition ‰Nasal ‰External ears ‰Hearing Neck ‰Exam ‰Thyroid Resp ‰Auscultation ‰Effort ‰Percussion ‰Palpation CV ‰Auscultation ‰Palpation ‰Edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses Breasts ‰ Inspection ‰Palpation / \ GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac \ / GU ‰Scrotum ‰Penis ‰Prostate ‰Urethra _ __ I I __ _ Gyn ‰External ‰Bladder ‰Cervix ‰Uterus ‰Adnexa \ / I \ / Lymph ‰Neck ‰Axilla ‰Groin ‰Other \_/ I \_/ Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength I Skin ‰Inspection ‰Palpation / \ Neuro ‰CN ‰DTR ‰Sensation / \ Psych ‰Affect ‰Orientation ‰Insight ‰Memory \ / Additional Findings _ _\ /_ _ This patient may benefit from Impression Code Status ‰Patient is a FULL CODE ‰DO NOT ATTEMPT RESUSCITATION Schedule ‰Influenza vaccine ‰Pneumococcal vaccine ‰Colonoscopy ‰Mammogram ‰Cardiac Stress Test ‰Echocardiogram ‰Other ‰Completed advance health care directives in chart œ47 HCPOA is ‰Labs ‰Consult ‰Follow Up Signature cc Data Reviewed Care Coordinated With ‰ ER Notes ‰ Old Chart ‰EMS Note ‰ECG ‰Nursing Notes & Vitals log ‰ Labs ‰ X Rays ‰MRI ‰US ‰CT ‰ER MD ‰HCPOA ‰Primary Care MD ‰Case Management ‰Social Worker ‰Pharmacy ©MB and RR 2006-2008 Revised1Sep08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services

Last update 9/1/08

Template Features

E&M Documentation Template
Digital Health Record
Reminders
- Follow Up
- Referral
- Labs
- Therapeutic options
- Medicare PQRI

Shopper Support

E & M Documentation Template

The clinic H&P MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.

History
- Chief complaint
- History of present illness
- Past medical and surgical history
- Social history
- Family history
- Review of systems
Examination
Medical Decision Making
- Review of data (labs, tests, imaging, old records)
- Assessment and plan
1997 Documentation Guidelines for Evaluation and Management Services
1995 Documentation Guidelines for Evaluation and Management Services

Digital Health Record

The clinic H&P MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes. This allows information to be typed in or pasted from other applications to fill out the template.

Filled clinic H&P MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.

To learn more about how MedicalTemplates can be used as a digital health record, click here.

MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader. With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.

MedicalTemplates

admin — Sun, 14 Sep 2008 18:49:48 +0000

Physician Friendly Patient Encounter Documentation Tools

MedicalTemplates are an efficient, affordable, and professional medical note templates built with Adobe PDF fillable form technology.

Clinic History and Physical MedicalTemplate - Upload a Document to Scribd

Fillable Adobe PDF forms

E&M Documentation Templates

Shopper Support

MedicalTemplate Bundles - Save 15-25%!

Primary Care | Chronic Disease Management | Pulmonary | Pulmonary Disease

MedicalTemplates are physician designed and tested medical note templates for a variety of clinical settings including -

Primary care clinics
Specialist clinics
Hospitals
ICUs

MedicalTemplates were developed to help physicians and other health care providers satisfy the stringent clinical documentation requirements before health insurance companies, Medicare, or Medicaid will pay for medical services.

Pay for performance initiatives such as the Medicare Physician Quality Reporting Initiative (PQRI) impose additional documentation requirements to satisfy quality measures.

Some MedicalTemplates incorporate reminders for Medicare PQRI Quality Measure Reminders

MedicalTemplates can improve the legibility and appearance of many medical notes including -

SOAP notes
History and physical exam notes
Consult notes
Progress notes

MedicalTemplates provides intuitive and easy to use documentation prompters to help satisfy documentation requirements for billing and pay for performance measures.

Checklists for important medical data, examination findings, and common testing and treatment options further improve the efficiency and consistency of healthcare note writing.

MedicalTemplates prompters are based on the HCFA 1997 Evaluation and Management documentation guidelines.

e-MedTools

Hospital H&P Medical Note Template

Template Features

E & M Documentation Template

History

Examination

Medical Decision Making

Medical Documentation References and Resources

Digital Health Record

Digital Signature Enabled

Adobe Reader Required

Clinic H&P

Clinic H&P Medical Note Template

Template Features

E & M Documentation Template

Digital Health Record

MedicalTemplates

Physician Friendly Patient Encounter Documentation Tools

MedicalTemplates are physician designed and tested medical note templates for a variety of clinical settings including -