Physician
Friendly Patient Encounter Documentation Tools
MedicalTemplates are an efficient, affordable, and
professional medical note templates built with
Adobe
PDF fillable form
technology.
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 İMB 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 İMB 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
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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.
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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.