The sepsis evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected sepsis, SIRS, or septic shock.  The sepsis evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity, including critical care. When completed, and in conjunction with a supporting level of medical decision making, the sepsis evaluation MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service. How to use MedicalTemplates

Sepsis Evaluation MedicalTemplate

E & M Documentation Template

The sepsis evaluation MedicalTemplate contains prompters and space for all the required elements for a new or subsequent inpatient E&M encounter.  

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.

• History  Click here to learn about History Documentation

• When completed, this document is a comprehensive (highest) level history as defined in 1997 Guidelines for E&M Services.
  
• 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, this document is a comprehensive (highest) level physical exam as defined in 1997 Guidelines for E&M Services.
  
• General Multisystem Exam OR Respiratory System 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

• 1997 Documentation Guidelines for Evaluation and Management Services 
• 1995 Documentation Guidelines for Evaluation and Management Services 
• HGSA Documentation worksheet 
• Trailblazer Health documentation worksheet (for DE, MD, TX, VA, or the DC)
• Medicare Audit and/or Coding Worksheet
• TrailBlazer Medicare Audit and/or Coding Worksheet

Digital Health Record

The sepsis evaluation 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 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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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.