The clinic history and physical (clinic H&P) medical documentation template is suitable for internal medicine physicians, family practice physicians, and other health care providers.
This note can be used as a 1997 E&M guideline-compliant new patient evaluation in outpatient settings.
Licenses for our medical documentation templates start at $99 for a single user. Volume discounts are available.
When completed, and in conjunction with a supporting level of medical decision making, this medical documentation template meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.
What needs to be documented for E&M services?
The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.
Documentation Components from the 1997 Guidelines:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Medical Decision Making (MDM)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality
How can I use this medical documentation template to improve medical billing?
Using this documentation template will give you the confidence to bill at the highest level that is appropriate for the medical service you provided. This will maximize your clinical revenue and may help you identify ways to improve your documentation to reduce your RAC audit risk.
Selecting the appropriate level for E&M services is challenging for most physicians. Studies show that 30-80% of outpatient E&M services are under coded, representing millions of dollars of lost practice revenue per year [Holt 2010].
References for this outpatient new patient evaluation medical documentation template
- HGSA Documentation worksheet
- 1997 Documentation Guidelines for Evaluation and Management Services
- 1995 Documentation Guidelines for Evaluation and Management Services
Important note about medical decision making
Health care providers in Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service must used the method developed by Trailblazer Health, the local Medicare Carrier, to determine the complexity of Medical Decision Making.
Requirements to use the Clinic H&P medical documentation template
This medical documentation template is in the Adobe PDF format, which requires the free Adobe Reader to function. With Adobe Reader, these templates can be filled out and printed as many times as you need.