New Inpatient Evaluation (History and Physical)

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15,238

Uploaded:

09/12/2008

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Research>Health & Medicine

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The hospital history and physical (Hospital H&P) MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice ph... (More) The hospital history and physical (Hospital H&P) MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers who evaluate and treat patients in hospitals.

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 hospital H&P MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new hospital patient evaluation or inpatient 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 disease (occupational exposures, 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 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 (Less)