You are on page 1of 1

Time Provider

Tobacco Cessation Chief Complaint


Clinic Here to participate in the tobacco cessation program.
Clinic Code 94

Time Primary Provider


Quit Date: _________________

___________________________________________________________ Vital Signs


Temp
___
Pulse Resp
___________________________________________________________
BP
___
___________________________________________________________ Ht Wt
Carbon Monoxide:
___
Health Factors
___________________________________________________________
[] Non-tobacco user
___ ICD xx Purpose(s) of Visit
Rank [] Current smoker
305.1 Tobacco use disorder Cigarettes/day __________
V65.4 Session 0:
[] Current smokeless
2-0
Cans of snuff/wk ________
V65.4 Session 1:
2-1 [] Cessation Smoker
V65.4 Session 2: Quit date_______________
2-2
[] Cessation Smokeless
V65.4 Session 3:
Quit date_______________
2-3
V65.4 Session 4: [] Previous (ex) Smoker
2-4 for_________years / mos
V65.4 Session 5:
2-5 [] Previous (ex) Smokeless
V65.4 Session 6: for________years / mos
2-6
[] Smoker in Home
V65.4 Session 7:
2-7 [] Ceremonial use only
V654. Stage of Change: Pre-contemplation (Tobacco Use)
0 [] Environmental exposure
V654. Stage of Change: Contemplation (Tobacco Use) ETOH
0 CAGE: 1 2 3 4 /4
V654. Stage of Change: Preparation (Tobacco Use)
0
V654. Stage of Change: Action (Tobacco Use) Education
Patient
D Topic Time Understandi Provid Goals Comments/Narrative
ng e
r
TO Complications G F P R GS GM
GP GNM
TO Disease process G F P R GS GM
GP GNM
TO Exercise G F P R GS GM
GP GNM
TO Follow-up G F P R GS GM
GP GNM
TO
PlansMedications G F P R GS GM Brief/Nurse Visit 99211 Healthy Visit
for next visit/Instructions/Referrals: 993____
GP GNM (New) Minimal, Self Limited (Estbl)
99201 CC Hist 3, ROS 0, 1 organ sys/ body 99211
99202 99212
area
99203 CC Hist 3, ROS1, 2-7 o. s./ b.a. 99213
99204 CC Hist4, ROS 2-9, 2-7 o. s./ b.a. 99214
Signature: Next Appt: 99205 Health & Behavior Intervention 99215
961453
Prolonged Visit 1st Hr Counseling :__15 min__ 30 min __60min
«patient» Chart: «chart» 99354
«timestamp» 9940_
DOB: «dob» SSN: «ssn» VCN: «uid»
Insurer: «b27»