Physician Friendly Patient Encounter Documentation Tools MedicalTemplates are an efficient, affordable, and professional medical note templates built with Adobe PDF form technology to help physicians and other health care providers satisfy the stringent clinical documentation requirements of health insurance companies, Medicare, and Medicaid.
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
E&M Documentation Templates
MedicalTemplates are physician designed and tested medical note templates for a variety of clinical settings including -
Primary care clinics
Specialist clinics
Hospitals
ICUs
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.
