The pneumonia evaluation medical documentation template is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers that evaluate patients with known or suspected pneumonia in ambulatory or hospital settings. This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with pneumonia.
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.
Impact of Pneumonia on the US Healthcare system
Statistics from the U.S. Department of Health and Human Services show pneumonia to be the eighth leading cause of death in the United States, causing about 90,000 deaths per year. Each year pneumonia affects 4 million Americans, is responsible for 1 million hospital admissions, and results in 10 billion dollars in health care costs. The overall mortality rate of pneumonia is 13 percent, and is influenced by factors such as age, living in a nursing home, or having cardiac or renal disease. The large numbers of people affected by pneumonia and the associated health care costs make pneumonia care a focus for many health care quality improvement initiatives.
Features of the Pneumonia medical documentation template
The Pneumonia Evaluation medical documentation template contains prompters for ascertaining different symptoms associated with pneumonia, such as dyspnea, chest pain, pleuritic pain, cough, fever, chills, nightsweats, and hemoptysis. Other prompters help identify patients who are at higher risk of aspiration pneumonia, multi-drug resistant infections, or infections due to less common causes including fungus, legionella, SARS, avian influenza, tuberculosis, and other microbes. Questions to document smoking history, drug abuse (both prescription and street drugs), and alcohol abuse are included to identify patients who are at increased risk of certain types of pneumonia.
Differentiating pneumonia from other medical conditions that produce a similar appearance on a chest x-ray challenging. The Pneumonia Evaluation medical documentation template includes prompters to help identify patients who may have other medical conditions such as myocardial infarction, heart failure, vasculitis, inhalation injury, or esophageal rupture that can cause produce a pneumonia like appearance on chest x-ray.
Pneumonia Severity Index
This medical documentation template includes the pneumonia severity index (PSI) which was developed by an Agency for Healthcare Research and Quality-funded multidisciplinary research team called the Pneumonia Patient Outcomes Research Team (PORT). This reliable and well tested decision support tool can assist physicians in determining if a pneumonia patient should be treated at home or in a hospital.
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: Medical History
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Physical Exam 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 Pneumonia 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 Pneumonia Evaluation 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.