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Asthma Evaluation Medical Note Template

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The asthma evaluation MedicalTemplate is suitable for any health care provider that manages patients with asthma.   This one page medical note template contains detailed checklists for the severity of asthma symptoms, current and planned asthma therapy, and other features helpful for a comprehensive asthma treatment plan.

How to use MedicalTemplates

Asthma Patient Evaluation PQRI - Upload a Document to Scribd Read this document on Scribd: Asthma Patient Evaluation PQRI Asthma Clinic Followup Date Time ROS Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych WNL See HPI Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Chief Complaint or Reason For Visit HPI Allergy list reviewed Medication list reviewed Asthma Symptom Frequency 64 Chest tightness, cough, wheeze, dyspnea Needed more “rescue agent” than usual Difficulty breathing Coughing, especially at night Nocturnal wakening due to chest tightness, wheezing or dyspnea Throat Eyes Nose Wheezing Chest tightness Itchy Antibiotic use Oral steroid use ER visit for asthma Hospital admission for asthma Discharge Medications from hospital/ER visit reconciled 46 Pulse I II 1+ days per week OR 1+ nights per month 2+ days per week OR 2+ nights per month Daily OR 2+ nights per week Continual OR Frequent Fatigue # symptom free days last 14 days Peak flow Best Worst Physical Exam General ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro Alert Mucosa Checked box indicates findings are within normal limits Vitals Dentition Thyroid Ht Wt Oropharynx No JVD Temp Mallampati BP III IV RR Sats Palpation Auscultation Clear S1 S2 Percussion No murmur Respiratory effort No gallop Palpation Chest wall No peripheral edema History No changes See HPI Allergies PMSH Social Family No rub Peripheral pulses No palpable masses No lymphadenopathy Tone Gait No hepatosplenomegaly No hepatojugular reflux Digits without clubbing or cyanosis No rashes, ecchymoses, nodules, ulcers Oriented (person, time, place) Affect Asthma Severity Mild Intermittent Mild persistent Moderate persistent Severe persistent Impression and Plan Tests to be ordered Bronchoscopy Pulmonary Function Testing Sleep study CXR Chest CT with contrast Echocardiogram with Pneumococcal vaccine Influenza vaccine PPD Testing Allergy skin testing Labs Asthma Therapy Current New Short-acting beta agonist “Rescue Agent” Inhaled steroid 53 Long-acting beta agonist Omalizumab Oral steroids Antibiotics Leukotriene inhibitor Oral antihistamine Intranasal steroids Intranasal antihistamine Smoking cessation aids Follow Up Instruction & Education Asthma Action Plan Goals Green Yellow Red Environmental trigger reduction Smoking cessation Peak flow meter use Proper Inhaler use Importance of vaccinations Medication side effects Signature cc Code Status Patient is a FULL CODE DNAR Patient has completed advance health care directives 47 HCPOA is Data Reviewed ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Case Management Labs X Rays MRI Pharmacy US CT Care Coordinated With ER MD HCPOA Primary Care MD Social Worker ©MB and RR 2006-2008 Revised 2May08

Template Features E&M Documentation Template Digital Health Record Reminders Follow Up Referral Labs Therapeutic options Pay for performance (P4P) reminders Medicare PQRI Measures   Shopper Support Terms of Sale

E & M Documentation Template

The asthma evaluation 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 

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Digital Health Record

Filled asthma evaluation 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.

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Medicare PQRI

Reminders for Medicare PQRI quality measures for asthma assessment, asthma therapy, medication reconcilliation, and advanced care planningare included in the asthma evaluation MedicalTemplate.

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Pay for Performance (P4P)

These clinical performance measures are used by many P4P programs.

The Clinical Performance Measures for Asthma can be downloaded from here.

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