Description

The Pulmonary/Critical Care new patient evaluation MedicalTemplate is suitable for pulmonologists, critical care physicians, intensivists, hospitalists and other health care providers who evaluate patients with pulmonary or critical illnesses.

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.

The pulmonary/critical care new patient evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a H&P or Consult.

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History
o Chief complaint
o History of present illness
o Past medical and surgical history
o Social history
+ Risk factors for respiratory disease (occupational exposure, smoking, and others)
o Family history
o Review of systems
+ Yes/No checkboxes for clear and complete documentation

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Examination
o When completed, represents a comprehensive (highest) level physical exam as defined in 1997 Guidelines.
o Respiratory Single System Exam OR General Multisystem Exam
o Checkboxes for pertinent negatives and common positive findings

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Medical Decision Making
o Full page for adequate space with complex patients
o Easy Documentation with checkboxes
+ Review of labs, tests, imaging, old records
+ Coordination of care
+ Common diagnostic and therapeutic options
o Assessment and plan