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I know you know this but, like anything else in medicine because something is true this year it may not be so next year. So, although I have done my best to accurately portray the rules, compose templates that are compliant and convenient so that you may render effective and proper care; It is your job as a physician to confirm, use your best judgment, and consult when necessary. If you find any errors or necessary changes let me know. You also know because this material is copyrighted, while I authorize you to use all or any part of this material freely, you may not however, reproduce, distribute, or make any part of this material into a derivative work for sale for financial gain without my permission. Thanks, Ted Christou, MD INDEX Page Title 1 Index Paper color Hole punch Paper weight 2 Initial H&P Template Front White 3 Problem List Front White 4 Problem List Back White 5 Long Progress Note Front Yellow 6 Long Progress Note Back Yellow 7 Short Progress Note Front Yellow 8 Short Progress Note Back Yellow 9 Patient Registration Front White 10 Review of Systems Back White 11 Pre-Op Evaluation Front White No 24# 12 Geriatric Evaluation Front White No 24# 13 Injury Report Front White No 24# 14 Consultation request Front White No 24# 15 Medical Release Front White No 24# 16 HIPAA Front Blue No 24# 17 Blood Tests Front No 24# 18 Preventive Care Back 19 Patient Medication Card 20 Wallet cards 21 Morning Schedule Front White 3 ring 24# 22 Afternoon Schedule Front White 3 ring 24# 23 Sign in Sheet White 20# 24 Super Bill Front White Carbonless copy 25 Visit Information Front Blue 24# 26 Exam Room Prompts Front White 24# 27 Quit Smoking Front Pale yellow 24# 28 Quit Smoking Back Pale yellow 29 Weight Loss Front Pale Green 30 Weight Loss Back Pale Green 31 Home Health Forms White 24# 32 Face to Face encounter White 24# 33 Retention of Medical Record White 24# 34 Immunization From White 24# 35 Approximate visit times 36-37 Medical Records Relief 38-41 Coding infromation 24# 2 left side 24# 2 left side 24# 2 left side 24# 2 left side 24# 24# White Folded Card stock Card stock Name Address Ph: 24# Fx: Enter 3-4 lines of heading to personalize these forms Name Address Ph: Time in A B H ME NA W Patient Fx: Date Initial History and Physical Template Time out DOB CC: Sweats chills fevers LOC ∆ appetite ∆ weight HPI: location, quality, severity, duration, timing, context, modifying factors, associated symptoms Depression anxiety ∆ memory ∆ sleep tired dizzy Headaches ∆ vision ears throat sinus ∆ voice epistaxis Chest pain-pressure palpitations DOE Orthopnea SOB wheezing cough PND edema sputum hemoptisis Food intolerance pain dysphagia dyspepsia bloating Dysphagia nausea vomiting hemorrhoids blood ∆ BM Nocturia LMP dysuria G: incontin P: frequency blood A: ∆ libido monogamous high risk Joint muscle pain stiffness weakness numb cramps Skin lesions rashes ulcer bruising ∆ nails ∆ hair MEDICATIONS: NP HPI/ROS PFSHx Exam DX Complexity ALLERGY Tobacco____c/day: never past yr quit______ pk/yrs ____ ADL Toilet Self Assist Feed Self Assist Dress Self Assist PM Hx:I DM II HTN CAD CHF CA _______________ Stroke CKD A Fib ESRD Groom Self Assist S Apnea PE Sx: Colon Bath Self Assist Cane Alcohol: never past social daily Walker Pacer Wheelchair Prostate PVD Seizures DVT Hyst Jaundice Ulcers Asthma Hip R ICD L Stents Lipidemia GERD Arthritis Pneumonia TB • Knee R CABG Vasc L BP sitting Height BP Psych L Bladder Resp Neck Palpation Thyroid Resp Effort Breath sounds Percussion Fremitus CV Palpate PMI thrill Heart sounds No murmur Carotids Aorta Femorals Pedal pulses Varicose veins Edema Chest Inspect breasts Palpate breasts GU Scrotum Penis Prostate F Genitals Urethra Bladder Cervix Uterus Adnexa Skin Inspection Palpation Lymph Neck Axillae Groin Neuro CN II-XII DTR Sensation Cerebellar Drugs: never past present Employment: ___________________________Toxic Expos:________ Lives with:________________________________________ no sometimes daily Do you feel nervous or can't control worry? no sometimes daily Lost of interest or feel hopeless, or sad? • Kidney R L Pulse Diet: General Tube feeding Low Na Reg Irr Reg Irr Diabetic Peak Flow Waist Temp BMI Exam/Assessment/Plan: GI Scars Bowel sounds Consistency Tender • Mass Liver • spleen Hernia Ano-rectal Occult blood Psych Place Year Season Affect Insight Cooper 3 step command Mus/Skel Gait ≥ 50 ft Digits nails R ROM UE Strength tone LE ROM Strength tone Level 3 ≥9 3 >18 systemic High Social Hx: Edu: 1-6 7-12 13-16 17+ Pref Language_________ Glaucoma • Foot R Level 3 4-8 2-3 6-12 2 Moderate Family Hx: DM CAD HTN TB CVA CA______________ Thyroid COPD Stomach Breast R L • Cataracts R L Weight Eyes Vision ≥20/40 OU Conjunctivae Lids PERRLA Fundi lens • disc ENT- Mouth Ears external TM EAC right TM EAC left Hearing R = L Speech clear Nose mucosa • septum turbinates Teeth • gums lips Dentures Upper Lower Oropharynx tongue•mucosa glands•pharynx Anemia Level 1 1-3 1 1-5 1 Low L UE LE Discussed the following: Ordered CMP CBC BMP INR Lipids EKG HgbA1C INR Lipids TSH TT3 FT4 UA Colon CXR Mammo Dexa 2D echo Stress Healthy lifestyle Smoking Cessation Limiting ETOH Treatment Diagnosis Yr last: PAP/Prostate _______ Mammo _______ Colon _______ Pneumo _______ Td ______ copyright © Medical Record Relief 1998 www.isbi.org Patient DOB Allergy PROBLEM LIST Year Problem Diagnosis Surgery Year Problem MEDICATIONS Diagnosis 30 days Surgery 90 days IMMUNIZATIONS & SCREENINGS Measles OPV Mumps DPT Rubella HBV HIB Pneumonia Td Varicella Influenza TdAP Echo/Stress Colon PAP / PSA Mammo copyright © Medical Record Relief 1998 www.isbi.org PROBLEM LIST Continued Year Problem Diagnosis Surgery Year Problem MEDICATIONS Continued Name Address Ph: Fx: Diagnosis Surgery Progress Note Patient Weight BP sitting Height BP Pulse Temp RR DOB Age CC: Changes from initial ROS HPI: Sweats chills fevers weight appetite sleep fatigue Vision headache dizzy ears throat sinus voice PND palpitations edema chest pain pressure SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Changes from PFSH General: Reviewed Medication List Objective: √ = examined explain Eyes Vision ≥20/40 OU Conjunctivae Lids PERRLA Fundi lens • disc ENT- Mouth Ears external TM EAC right TM EAC left Hearing R = L Speech clear Nose mucosa • septum turbinates Teeth • gums lips Dentures Upper Lower Oropharynx tongue•mucosa glands•pharynx No Circle = normal Neck Palpation Thyroid Resp Effort Breath sounds Percussion Fremitus CV Palpate PMI thrill Heart sounds No murmur Carotids Aorta Femorals Pedal pulses Varicose veins Edema Chest Inspect breasts Palpate breasts GU Scrotum Penis Prostate F Genitals Urethra Bladder Cervix Uterus Adnexa Skin Inspection Palpation Lymph Neck Axillae Groin Neuro CN II-XII DTR Sensation Cerebellar Assessment • Plan • Data Yes L UE LE Focused 1-3 0 1-5 element 1 Expanded 1-3 Pertinent ≥6 element 2 Detailed Compreh ≥4 ≥4 2-9 ≥9 ≥12 element ≥18 element systemic severe Te BMP CBC Lipids INR HgA1C UA Urine C&S Strept Screen CXR TSH T3 T4 FTI Mammo EKG Colon Exam Mammo Name Address Ph: GI Scars Bowel sounds Consistency Tender • Mass Liver • spleen Hernia Ano-rectal Occult blood Psych Year Season Affect 3 step command Mus/Skel Gait Digits nails R ROM UE Strength tone LE ROM Strength tone HPI ROS Exam DX Tests ordered: CMP Reviewed Problem List Circle abnormal and Yes Strep Colo Fx: Reviewed and discussed diagnostic tests Advised on Treatment Follow-up Signature Date Progress Note Age Weight BP sitting Height BP Pulse Temp HPI ROS Exam DX RR Focused 1-3 0 1-5 element 1 Expanded 1-3 Pertinent ≥6 element 2 Detailed Compreh ≥4 ≥4 2-9 ≥9 ≥12 element ≥30 element systemic severe CC: Changes from initial ROS HPI: Sweats chills fevers weight appetite sleep fatigue Vision headache dizzy ears throat sinus voice PND palpitations edema chest pain pressure SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Changes from PFSH General : Reviewed Medication List Objective: √ = examined Eyes Vision ≥20/40 OU Conjunctivae Lids PERRLA Fundi lens • disc ENT- Mouth Ears external TM EAC right TM EAC left Hearing R = L Speech clear Nose mucosa • septum turbinates Teeth • gums lips Dentures Upper Lower Oropharynx tongue•mucosa glands•pharynx No Circle = normal Neck Palpation Thyroid Resp Effort Breath sounds Percussion Fremitus CV Palpate PMI thrill Heart sounds No murmur Carotids Aorta Femorals Pedal pulses Varicose veins Edema Chest Inspect breasts Palpate breasts Circle abnormal and explain GU Scrotum Penis Prostate F Genitals Urethra Bladder Cervix Uterus Adnexa Skin Inspection Palpation Lymph Neck Axillae Groin Neuro CN II-XII DTR Sensation Cerebellar GI Scars Bowel sounds Consistency Tender • Mass Liver • spleen Hernia Ano-rectal Occult blood Psych Year Season Affect 3 step command Mus/Skel Gait Digits nails R ROM UE Strength tone LE ROM Strength tone Reviewed Problem List Yes Yes L UE LE Assessment • Plan • Data Tests ordered: CMP BMP CBC Lipids INR HgA1C UA Urine C&S Strept Screen CXR TSH T3 T4 FTI Mammo EKG Colon Exam Mammo Reviewed and discussed diagnostic tests Advised on Treatment Follow-up Signature Date Progress Note Name Address Ph: Weight BP sitting Height BP Patient Fx: Pulse Changes from initial ROS Temp RR Sweats chills fevers weight appetite sleep fatigue Vision headache dizzy ears throat sinus voice CC: PND palpitations edema chest pain pressure HPI: SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Changes from PFSH Reviewed Medication List Reviewed Problem List Discussed Yes Yes Ordered diagnostic tests Advised on Medications / Treatment Weight BP sitting Height BP Follow-up Pulse RR Signature Date Changes from initial ROS Temp Sweats chills fevers weight appetite sleep fatigue Vision headache dizzy ears throat sinus voice CC: PND palpitations edema chest pain pressure HPI: SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Changes from PFSH Reviewed Medication List Reviewed Problem List Discussed Ordered diagnostic tests Advised on Medications / Treatment Follow-up Signature Date Yes Yes HPI ROS Exam DX Focused 1-3 0 1-5 element 1 Expanded 1-3 Pertinent ≥6 element 2 Detailed Compreh ≥4 ≥4 2-9 ≥9 ≥12 element ≥18 element systemic severe Changes from initial ROS Weight Sweats chills fevers weight appetite sleep fatigue Height Vision headache dizzy ears throat sinus voice BP sitting Pulse BP Temp RR CC: CC: PND palpitations edema chest pain pressure HPI: SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Changes from PFSH Reviewed Medication List Reviewed Problem List Discussed Yes Yes Ordered diagnostic tests Advised on Medications / Treatment Changes from initial ROS Follow-up Weight Sweats chills fevers weight appetite sleep fatigue Height Vision headache dizzy ears throat sinus voice Signature BP sitting Date Pulse BP Temp RR CC: PND palpitations edema chest pain pressure HPI: SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Changes from PFSH Reviewed Medication List Reviewed Problem List Discussed Yes Yes Ordered diagnostic tests Advised on Medications / Treatment Follow-up Signature Date Name Address Ph: PATIENT REGISTRATION Personal Asian Man Black Woman Hispanic Single Native American Married Fx: Divorced White Widowed Multiethnic Separated Preferred Language______________ Patient Name Birth date Street City State Social Security Number Phone ( Zip code Pharmacy Phone ) Cell Phone Responsible for bills: Self ( ) ( ) or name and relationship Address (if different from above) Phone In an EMERGENCY notify Employment Are you employed? YES NO ( RETIRED ) Toxic exposures? YES NO Type of work you do or did Current Employer Address Insurance Work Number Medicare HMO PPO Primary Insurance Company __________________________________ Address Phone __________________________________ Traditional ( ) Public Aid Secondary Insurance __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Policy Number __________________________________ __________________________________ Group Number Treatment and payment agreement I authorize examination and treatment for this and all following physician visits. I authorize to release any medical information necessary to process insurance billings. I authorize payment and assignment of insurance benefits to the doctor’s office. I am personally responsible for supplying accurate and current insurance information. I understand I am financially responsible for all charges and deductibles not covered by my insurance and/or if I supply false or incorrect billing information. I authorize a photocopy of this statement to serve as an original. Signature: Date: copyright © Medical Record Relief 1998 www.isbi.org COMPREHENSIVE REVIEW OF SYSTEMS Constitutional √ = asked No Circle = normal Circle and explain if present Gastrointestinal Respiratory Describe Sweats Swallowing problem Shortness of breath Chills Heartburn Cough Fevers Bloating Sputum Trouble sleeping Ulcers Coughed up blood Appetite change Abdominal pain Choking at night Weight change Nausea Asthma Abuse • Fear harm Vomiting Breathless when flat in bed Depression Diarrhea Snoring Anxiety • Panic Constipation Breathless with walking Head Neck Neuro Bowels irregular Vision Changes Cardiovascular Blood in stool Chest pressure Eye Pain Mucus in stool Chest pain Headaches Food intolerances Palpitations Dizzy • Vertigo Jaundice Wake up breathless Hearing problem Hemorrhoids Ankle swelling Ringing in the ears Genitourinary Leg cramping Hoarseness Sexually active Varicose veins Sinus • Nose bleeds Multiple partners Cold feet or hands Smell • Taste High risk sex Passing out Oral Lesions Infections Dry mouth Change in sex drive Falls Teeth • Gums Menstrual disorder Joint stiffness Neck or jaw pain Menopause Joint pain Thyroid • Goiter Incontinence Joint swelling Swollen glands Frequent urination Muscle aches Musculoskeletal Tics • Tremors Urge to urinate Weakness Memory loss Painful urination Change in moles Seizures Blood in Urine Change in nails Discharge Change in hair L • R Handed ADL Yes Toilet Self Groin itching Rashes • Bumps • Bruises Awaking to urinate Fractures Change in stream Numbness Feeds Self Dress Self Last period Groom Self Pregnancies Walk 50 ft Live births Bathe Self Abortions Tingling Low Back Pain Blood clots • Phlebitis Deformity • Amputation Family Medical History Diabetes brother sister mother father grandparent Heart problem Hypertension Diabetes I II Heart/Circulation problem brother sister mother father grandparent brother sister mother father grandparent M P Pneumonia TB brother sister mother father grandparent brother sister mother father grandparent M P M P Stroke Ulcers Asthma Surgical History M P Gallbladder Tuberculosis R L Hysterectomy Appendix Hip • R L Knee • R L Foot Colon Bypass Stomach Prostate R L Breast Pacemaker Stents Bladder R L Hernia Tonsils R L Cataract Implants Heart-Valve Completed by Patient Completed by Staff Thyroid Hypertension Cancer Glaucoma Arthritis COPD M P Cancer Stroke Medical History Reviewed by physician Signature Date Pre-Surgical Evaluation Name Patient: Address Ph: Pre-Surgical Orders Fx: D.O.B. Age: Date of surgery: Surgeon: Diagnosis: Recommendations: Include reason for surgery any significant history, precautions, anticipated complications. Medications Smoker: Yes PMHx: No Daily ETOH: Yes No Diabetes Pulmonary Hepatic Warfarin Hypertension Cardiac Renal Antiplatelet Functional Hx: Can patient climb 1 flight of stairs? Anesthesia: General Ordered CBC CMP Yes Regional EKG No MAC CXR Local INR UA Other Orders: Cardiac Clearance: Needs Cardiac Clearance Pre-op diet: Cardiac Clearance Done Dr. Standard NPO Take √ meds with sips of water Examination: Weight BP sitting Temp Height Pulse RR No Significant Abnormality Reviewed CBC Reviewed Chemistry panel Describe Abnormal EKG report noted HEENT Xray report noted Lungs Reviewed Coagulation profile Heart Urine noted Abdomen Reviewed physician consultation Extremities Need for Beta -blocker: Yes No ALLERGY Anesthesia review Surgeon review Preoperative Evaluation Class I Healthy no medical Problems - Low Risk Class II Mild systemic disease - Low Risk Procedure Class III Severe systemic disease stable - Moderate Risk Class IV Severe systemic disease unstable - High Risk copyright © Medical Record Relief 1998 Signature www.isbi.org Date GERIATRIC SCREENING FOR: Depression/Anxiety - Screen DOB: Total score > 3 for 1 & 2 = anxiety PHQ4 Depression screen 0 score > 3 for 3 & 4 = depression 1 2 3 1. Do you feel nervous or anxious? No sometimes most of the time all the time 2. Are you able to stop or control worry? Yes mostly sometimes no 3. Little interest in pleasure or doing things? No sometimes most of the time all the time 4. Do you feel sad, hopeless, or down? Yes usually sometimes No Who do call when you need help? Function Sensory YES NO 1 0 Able to read magazines or the paper 1 Able to use the toilet yourself? Able to understand spoken voice in either ear 1 Able to feed yourself? 1 0 Able to dress or groom yourself? 1 0 1 Do you pay your own bills? 1 0 Touch your knee, close your eyes, touch your nose 3 Any trouble using the phone? 0 1 Name this place 1 Any trouble operating the TV or radio? 0 1 What is the Season? 1 Can you pick up something you drop? 2 0 What is the month? 1 Maneuver within confines of your home? 2 0 Where were you born 1 Rise from chair, walk to the door and come back What is this called: Pen - Doorknob 2 Able to accomplish in 7-10 seconds 3 0 1 Able to accomplish in 10-20 seconds 1 0 Mental Status Repeat "hat - pencil - apple" for recall later How much is 2 quarters and a nickel? Points for naming: 0-2 =0 3-4 =1 5-7 =2 8-9 =3 10 =4 >10=5 Draw five past ten on the clock Points How many can you name: cities or towns 1 2 3 4 5 How many can you name: fruits or vegetables 1 2 3 4 5 Repeat the 3 objects "hat - pencil - apple" 11 12 1 10 3 2 9 3 4 8 Analysis of Geriatric Assessment: 7 5 6 Sensory Mental Status Function Most likely independent ≥1 ≥19 >10 Requires some supervision ≥1 16 - 18 8 - 10 Requires moderate supervision ≤1 6 - 15 3-7 Requires living arrangement with 24 hrs of care ≤1 <6 <3 Notes: Name Address Ph: Fx: Signature copyright © Medical Record Relief 1998 www.isbi.org Date INJURY REPORT Initial Patient: Follow-up DOB: Claim/Case Number: Insurance: Type of injury: motor vehicle work related Date of injury: other Date reported: Passenger Driver Wearing seat belt: Injury while wearing: back brace helmet Vehicle’s impact site: front Injury to: Head Neck rear Chest Employer: yes gloves no Air bag triggered: mask goggles driver side Abdomen yes no other passenger side Back R L Arm R L Leg Previous similar injury? Symptom(s) onset: At this visit symptoms are: Absent Improved Unchanged yes no Worse Subjective: Objective: Imaging or lab ordered: Treatment: Last day at work: Return to work: Restrictions: Still under care for same condition: yes no Anticipate surgery? yes no Referred to: Disability: partial total from to Name Address Ph: Signature Fx: Date copyright © Medical Record Relief 1998 www.isbi.org CONSULTATION REQUEST Name Address Ph: Fx: Consultant: Patient: Phone: Phone: Address: Evaluation Only Evaluate and Treat May Refer at your discretion Contact me before referring Signature:_____________________________ Please mail or Fax this note to our office at your earliest convenience. Thank you. DATE: Reason for consultation: Consultant’s findings: Signature: Date: If the patient fails to contact your office within 5 days please notify our office. This message is confidential and intended for the addressee only. Disclosure, copying, or communication of this message if you are not the addressee is prohibited by law. If you receive this Fax and are not the addressee please contact our office immediately. copyright © Medical Record Relief 1998 www.isbi.org Consent for Release of Medical Information Name Address Ph: Patient: Fx: DOB: Release From: Address: Release To: Phone: Fax: Phone: Fax: Address: Address: Records Requested: X-ray Report(s) Copy of Films/Imaging Study Laboratory Reports Diagnostic Studies Progress Notes Consultation(s) All Dates of records requested: Other From _____________ Records shall be used for: Acute care Please deliver records by: Fax to _________________ Continuation of care U.S. Mail Other Second opinion _____________________ This consent is valid for 30 days from the date signed. I hereby authorize “Release From” as stated above, to deliver to “Release To” as stated above the medical records as defined above by my _____ (1-9) check marks. I, the patient or patient’s representative have the legal right to inspect, copy and request delivery as specified of this Protected Health Information within the next 30 days in accordance with Public Law 104-191 (HIPAA-1996). I accept the responsibility for any fees that may be associated with this request. Patient Signature: Date: Patient’s Legal Representative: Date: Printed name of Legal Representative: This request is confidential and intended for the addressee only. Disclosure, copying, altering or communication of this message if you are not the addressee is prohibited by law. copyright © Medical Record Relief 1998 www.isbi.org Notice of Privacy Practices for Our Office Your medical record is called Protected Health Information (PHI) under Federal Law 104-191 - The Health Insurance & Patient Accountability Act of 1996 (HIPAA-1996) . As of March 1, 2003 all medical practices are required by law to notify you of your privacy rights, and we will post any changes to these rights on the examination room bulletin board. Use of Protected Health Information with your authorization. By signing the authorization to be treated on our “Patient Registration” you agree that your PHI may be used or disclosed by our office staff for the purpose of Treatment, Payment, health care Operations (TPO), or judicial proceedings and that we call you by name in our waiting room. You also may have authorized a release of your PHI by a written statement from your employer, attorney, or insurance carrier. Your PHI may be required for our business records, our computer/billing system, pharmacies, other physicians, laboratories, your employer, or therapists before they will process our request for TPO. You may revoke any authorization , provided we receive it in writing. What we mean by: Treatment - other treating personnel, pharmacists, testing facilities. Payment - for billing and electronic records your diagnosis and treatment dates are disclosed. Health care operations - compliance audits, public health, office administration or contractual requests. Judicial proceedings - any court orders, subpoenas, legal audits, or lawful demand. Use of Your Protected Health Information without your authorization. Your PHI may be disclosed as required by law, for public health activities, victims of abuse, health and oversight proceedings, law enforcement, judicial and administrative proceedings, funeral homes, research purposes, or specialized governmental functions. In such cases we will release information only if we have received a written request with documentation that the PHI disclosed is expressly authorized by the order. What we mean by: Law - if the law requires we will notify you of such disclosure. Public health activities - FDA, communicable disease, work related injury, instances of abuse or neglect. Health and oversight - a legal oversight agency for any investigation in which you are not involved. Law enforcement - properly issued subpoena, warrant, court order, or legal summons. Disclosure of Protected Health Information requiring your authorization. Our office does not E-mail or fax information, unless you request it in writing. We will not disclose your PHI to family members, personal representatives or guardians unless you request it. In an emergency we may disclose only relevant information if in our professional judgment it is in your best interest. You may request that we modify or do not use or disclose any or part of your PHI in order to carry out treatment, payment or heath care operations. This right to restrict does not extend to disclosures as required by law. You may inspect or request a copy of your PHI (in writing) to be sent to you or an alternative location or by alternative means. Our office has the right to charge a fee to cover supplies, labor costs, and postage. There may be an additional charge to prepare a summary or explanation of the records. The records shall be sent within 30 days from receipt of the written request and payment. If these copies can not be sent within 30 days we will notify you. I authorize the following people to have unlimited access to my PHI (any and all of my medical information): _________________________________ Print Name ______________________________ Relationship _____________ Date _________________________________ Print Name ______________________________ Relationship _____________ Date I have reviewed this notice of Privacy Practices and understand the address location and contact information for: the complete HIPAA-1996, and the Privacy Officer for this office is available upon my request, and also that compliance complaints can be made to the Department of Heath and Human Services. _________________________________ Print Name ______________________________ Signature _____________ Date copyright © Medical Record Relief 1998 www.isbi.org BLOOD TESTS....WHAT could they MEAN? Not sure, discuss YOUR results with the doctor. Glu • Fasting glucose higher than 120 is diabetes HgbA1C • Good control of diabetes if around 7.0 For Your Information BUN • When high may be dehydration or a kidney problem Creatinine • High in kidney problems or muscle disease GFR • Describes kidney function. If < 60 CKD Chronic Kidney Disease Cholesterol • Greater than 200 is a risk factor for heart attacks HDL • “Happy” Good Cholesterol should be greater than 40 LDL • “Lousy” Bad Cholesterol should be less than 100 Triglycerides • Fats in the blood should be less than 180 Cholesterol/HDL ratio • if greater than 5 higher risk for heart attack Uric Acid • Numbers greater than 10 predict gout attacks SGPT SGOT AST ALT Liver enzymes: When high can be related to alcohol use, liver abnormalities, hepatitis, infections, or medications that affect the liver. K (Potassium) • Muscle function, some medications affect level Na (Sodium) • Part of common table salt Ca (Calcium) • Muscle function and bone strength Cl (Chloride) • Part of common table salt Mg (Magnesium) • Needed for nerves to work properly PO4 (Phosphorus) • Needed for bones and muscle function C02 • Carbon dioxide is a byproduct of metabolism and measures the acid in your system. Lower numbers mean more acid. PSA • High in prostate cancer CA 125 • High in ovarian cancer TSH • High when you need more thyroid - Low if you have too much Protein Albumin Globulin Measure your nutritional and immune condition values change in some blood, kidney, liver problems Bilirubin • Bile in the blood, high in some blood or gallbladder problems Alkaline phosphatase • High in liver, bile duct, and bone diseases CBC • complete blood count, looks for anemia, infection, allergy WBC • white blood cells fight infection and go up in stress RBC • red blood cells carry oxygen in the body - low is anemia PLTS (platelets) • keep you from bleeding when you cut yourself Name Address Ph: Fx: copyright © Medical Record Relief 1998 www.isbi.org When was your last tune-up? Just like scheduled preventive maintenance for an automobile your body needs scheduled check-ups to run right. We have outlined the “tune-up” schedule we use in our office for particular age groups. The following preventive care is for those who are without symptoms. Some medical conditions, behaviors, or family history may alter how often tests or examinations are done; ASK THE DOCTOR! Preventive Care AGE 16-18 AGE Counseling Healthy lifestyle; tobacco use, sexual behavior, seat belts, alcohol use, dental care, substance abuse, guns 18-30 Tests Urine, cholesterol and blood sugar once Exam Heart murmur, blood pressure, testicular exam Counseling Healthy lifestyle; tobacco use, sexual behavior, seat belts, alcohol use, dental care, substance abuse, guns, tetanus and hepatitis B vaccine 30-40 Tests Urine, cholesterol and blood sugar three times Exam Blood pressure and Pap smear every other year with one complete physical Counseling Healthy lifestyle; tobacco use, sexual behavior, seat belts, alcohol use, dental care, substance abuse, guns, exercise, diet, tetanus vaccine 40-50 Tests Initial mammogram, Lipids and BMP every three years Exam Initial breast exam, every other year Pap Smear, two complete physicals Counseling Healthy lifestyle; tobacco use, sexual behavior, seat belts, alcohol use, dental care, glaucoma screening, substance abuse, exercise, diet, tetanus 50-65 Tests Initial PSA. Yearly mammogram, Cholesterol and blood tests Exam Four complete physicals including prostate exam and Pap smear Counseling Exercise, diet, tobacco use, sexual behavior, seat belts, alcohol use, dental care, glaucoma screening, menopause, substance abuse, tetanus 65+ Tests Yearly blood tests, mammogram and PSA. Colonoscopy every 3-10 years Exam Four complete physicals including a rectal exam, prostate exam, Pap smear Counseling Healthy lifestyle; tobacco use, seat belts, alcohol use, hearing screen, glaucoma screening, fall prevention, depression, exercise Tests Mammogram to 75. Colonoscopy every 3-10 yrs and blood tests yearly Exam End Pap smears, start yearly physical Other Influenza vaccine yearly, pneumonia & shingles vaccine once, tetanus Peak Flow Peak Flow • Measure Personal Best IS: Personal Best 10-20% drop: double the inhaled steroid-IS P: 20% drop RI: 30% drop 20% drop add 1 puff 2x’s daily of Primary inhaler - P 30% drop add Rescue inhaler 2 puffs 3x’s daily - RI 50% drop 50% drop add prednisone 20mg daily and call office Allergy: >50% drop go to the Emergency Room Name Address Ph: Fx: copyright © Medical Record Relief 1998 www.isbi.org My Medical Information Name: __________________________ Strikethrough when medication is stopped Medication and dose Pills per day 123 Birthdate: ______________ Allergy Illness or Surgery Year Enter the year of immunization Tetanus Pneumonia Influenza Dr. _____________________________ Dr. _____________________________ Dr. _____________________________ Dr. _____________________________ ______________________ Please bring this card to all doctor visits Pharmacy: copyright © Medical Record Relief 1998 Enter the month/year test was done Colon PAP/PSA Mammogram BMI LDL A1C www.isbi.org Peak Flow Peak Flow • Measure Personal Best IS: Personal Best 10-20% drop: double the inhaled steroid-IS P: 20% drop RI: 30% drop 20% drop add 1 puff 2x’s daily of Primary inhaler - P 30% drop add Rescue inhaler 2 puffs 3x’s daily - RI 50% drop 50% drop add prednisone 20mg daily and call office Allergy: >50% drop go to NEAREST Emergency Room Name Address Ph: Test Fx: mm/yr Result mm/yr Result mm/yr Result Pneumonia HgbA1C Flu Choles Date HDL BP LDL Tetanus BP BP BP Meds: PAP/PSA Allergy Colon Mammo Weight Blood Pressure Goal 120/80 Medications: Pharmacy: Wallet Cards are business card size. Have your name and contact number printed on the cards copyright © Medical Record Relief 1998 www.isbi.org BP BP BP Morning Schedule Date: Total collected √ $ 9:00 AM √ $ 9:15 AM √ $ 9:30 AM √ $ 9:45 AM √ $ √ $ 10:00 AM √ $ 10:10 AM √ $ 10:30 AM √ $ 10:45 AM √ $ √ $ 11:00 AM √ $ 11:10 AM √ $ 11:30 AM √ $ 11:45 AM √ $ √ $ 12:00 PM √ $ 12:10 PM √ $ 12:30 PM √ $ 12:45 PM √ $ √ $ 1:00 PM √ $ 1:10 PM √ $ 1:30 PM √ $ 1:45 PM √ $ √ $ Time Patient Phone Initial Exam simple problem 15 min. Initial Exam moderate problem 20 min. Initial Exam complex problem 30-40 min. Amount Follow up Exam simple problem 10 min. Follow up Exam moderate problem 15 min. Follow up Exam complex problem 20 min. Afternoon Schedule Date: Total collected Time Patient Phone Amount $$ 1:00 PM √ $ 1:15 PM √ $ 1:30 PM √ $ 1:45 PM √ $ √ $ 2:00 PM √ $ 2:10 PM √ $ 2:30 PM √ $ 2:45 PM √ $ √ $ 3:00 PM √ $ 3:10 PM √ $ 3:30 PM √ $ 3:45 PM √ $ √ $ 4:00 PM √ $ 4:10 PM √ $ 4:30 PM √ $ 4:45 PM √ $ √ $ 5:00 PM √ $ 5:10 PM √ $ 5:30 PM √ $ 5:45 PM √ $ √ $ Initial Exam simple problem 15 min. Initial Exam moderate problem 20 min. Initial Exam complex problem 30-40 min. Follow up Exam simple problem 10 min. Follow up Exam moderate problem 15 min. Follow up Exam complex problem 20 min. Name Address Ph: Fx: Office Sign in Sheet Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Print FIRST name ONLY Date:_____________ Initial of LAST name Date: Name Address Ph: Patient Fx: Address DOB Wellness Established Patient Phone Initial Medicare G0438 G0439 Minimal 99211 Annual Medicare Problem Focused 99212 Rectal Exam Low Complexity 99213 Tobacco cessation G0437 Moderate Complexity 99214 Alcohol misuse G0442 High Complexity 99215 Obesity New Patient G0102 V76.44 305.1 Please call the office after you have completed your testing. G0447 V85.30 Depression G0444 New age 18-39 99385 age 40-64 99386 Tests Ordered Today CMP BMP CBC INR Coronary Risk HgA1C Problem Focused 99201 New Expanded 99202 New age 65+ 99387 ESR RF Detailed 99203 Established 18-39 99395 ANA Uric Acid Comprehensive 99204 Established 40-64 99396 Colon Exam Upper GI PAP High Complexity 99205 99397 PSA 7 days Post Hospital DC 99496 Strept Screen CXR 14 days Post Hospital DC 99495 Established 65+ Procedures Injections/Immunizations Therapeutic Injection fee 96372 Fecal Occult Blood 82270 Depo Medrol 40 mg J-1030 Clear Ear Canal 69210 TB Skin Test 86580 I & D Abscess 10060 Tdap 90715/90471 V06.1 Injection of Bursa 20610 Hepatitis B 90746/G0010 V05.3 Injection of Tendon 20550 Influenza 90238/G0008 V04.81 Trigger point 20552 Pneumonia 90732/G0009 V03.82 Albuterol treatment 94640 Teaching MDI/neb 94664 Skin tag removal ≤ 15 11200 Wart destruction 17110 Suture Removal 99499 V74.1 Adult Td 90718/90471 V06.5 Administration fee 90657 Varicella-zoster 90736/90471 V05.8 Diagnosis: Abdominal pain Acne Allergic rhinitis Anemia Anxiety Arthritis Asthma Atrial Fib Bronchitis Bursitis Carpal Tunn Syn Cellulitis Cerumen Plug Chest pain CKD III Claudication Cong hrt failure Conjunctivitis 789.00 Constipation 706.1 Costochondritis 477.9 Cor art disease 285.9 Colitis 300.02 Dehydration 716.90 Depression 493.90 Dermatitis 427.31 Diabetes Insulin 466.0 Diabetes Non-Ins 727.3 Diarrhea 354.0 Disc disease spine 682.9 Edema 380.4 Emphysema 786.50 Fatigue 585.30 Gastritis 440.21 GERD 428.0 GI Bleed 372.30 Gout 564.00 733.6 414.01 556.9 276.51 311 692.9 250.01 250.00 787.91 722.0 782.3 492.8 780.79 535.00 530.11 578.9 274.9 Headache Hemorrhoids Hyperlipidema Hypertension Hypercholesterol Hypothyroid Hyperthyroid Incontinence Insomnia Low back pain Menopause Migraine Neuropathy Obesity Osteoporosis Otitis Media Palpitations Periph Vas Dis 307.81 Pharyngitis 462 455.0 Pneumonia 486 272.4 Psoriasis 696.1 401.1 Sinusitis 473.9 272.0 Sciatica 724.3 244.9 Spinal Stenosis 724.00 242.9 Strep throat .034.0 780.30 Stroke 436 780.52 Syncope 780.2 724.2 Tendonitis 726.90 627.3 Tonsillitis 463 346.90 Upper respir inf 465.9 355.9 Urinary tract Inf 599.0 278.00 Vaginitis 616.10 733.00 Vertigo 386.2 382.9 Vestibulitis 386.30 785.1 Warts viral .078.10 443.89 Weakness 780.79 TSH T3 T4 FTI Iron studies Stool C/S UA Urine C/S Mammo CT scan 2D Echo Stress Test Carotid doppler EKG Return - Visit PAYMENT CASH HMO CHECK PA INSURANCE MEDICARE NO CHARGE INSUR ONLY Charges Payment Balance Doctor’s Signature: WHAT IS AN MEDICAL VISIT? All doctors use CPT codes for medical visits. A code number that corresponds to the level of care must by chosen by the doctor at the end of the visit. The fee reflects the code: the higher the code, the higher the fee. Fees are also higher for a NEW patient compared to an ESTABLISHED patient for the same level of care. Each of the following components are considered when choosing the correct code for a visit. TIME: Face to face time spent with the patient varies from 10 to 75 minutes. HISTORY and PHYSICAL EXAMINATION: A Minimal visit doesn’t require the doctor to be present (nurse checks blood pressure). A Focused visit includes a brief history and exam of a single area or problem (visit for a blood pressure check). The Expanded visit includes related areas of the body for a single problem (uncontrolled HTN). A Detailed or Comprehensive history and physical examination includes a review of related as well as unrelated symptoms, pertinent past medical, social, and family history and a more expansive physical examination for complex or multiple problems (chest pain and confusion from malignant HTN). The outpatient visit is coded at a higher level for multiple problems. SEVERITY: How serious and what are the consequences of the presenting medical problem? COMPLEXITY: Medical decisions are made by considering the following issues: • What is the most probable diagnosis? • What are the possible diagnoses, treatment, and management options? • What tests if any, should be ordered, reviewed, and interpreted? • What is the risk or complication of the decision: low, moderate, or high? COUNSELING: Discussing lifestyle changes, personal or medical dilemmas. COORDINATION OF CARE: Discussion and planning with other health care professionals. MINIMAL FOCUSED EXPANDED DETAILED Office New 99201 99202 99203 99204 99205 Home NEW 99341 99342 99343 99344 99345 99324 99325 99326 99327 10 min 10-20 min 25- 30 min 30-45 min 45-75 min Domiciliary NEW TIME COMPREHENSIVE HISTORY None Focused Expanded Detailed Comprehensive PHYSICAL None Focused Expanded Detailed Comprehensive SEVERITY Minimal Low Moderate Moderate High COMPLEXITY Minor Simple Low Moderate High Office ESTABLISHED 99211 99212 99213 99214 99215 Home ESTABLISHED 99347 99348 99349 99350 Domiciliary ESTABLISHED 99334 99335 99336 99337 TIME 5 min 10-15 min 15- 20 min 20-40 min 40-60 min HISTORY None Focused Expanded Detailed Comprehensive PHYSICAL None Focused Expanded Detailed Comprehensive SEVERITY Minimal Low Moderate Moderate High Minor Simple Low Moderate High COMPLEXITY Minimal - Flu shot or brief follow up for a treatment the day before, doctor does not need to be present. Focused -single diagnosis, no testing, minimal risk. (blood pressure check, a cold or an insect bite) Expanded - two problems or stable chronic problem, limited testing, low risk. (controlled hypertension and diabetes) Detailed - single acute systemic illness or chronic illness(es) with exacerbation. (colitis, cellulitis, asthma) Comprehensive - single acute illness threatening function or chronic illness(es) with severe exacerbation. (pneumonia) copyright © Medical Record Relief 1998 www.isbi.org Exam Room Coding Prompts Cardiovascular Abdomen Musculo-Skeletal Skin 410.91 410.92 413.9 411.1 424.1 427.9 427.31 427.32 786.50 428.0 782.3 401.9 412 394.1 394.0 424.0 428.1 785.1 451.2 789.30 789.00 789.60 540.9 153.3 151.8 575.1 564.1 556.9 564.0 787.91 562.11 562.10 536.80 530.10 535.00 530.81 578.9 455.6 578.1 577.0 569.3 787.03 715.90 714.0 724.5 727.51 727.3 722.2 354.00 847.0 733.6 274.0 728.85 733.01 338.0 845.00 846.0 724.0 726.90 727.00 919.0 949.1 173.9 682.9 924.9 692.9 692.9 O53.9 708.9 214.1 681.02 681.11 685.1 696.1 692.71 692.9 AMI initial care AMI subsequent care Angina pectoris Angina unstable Aortic Stenosis Arrhythmia Atrial Fibrillation Atrial Flutter Chest pain CHF Edema HTN MI old Mitral Insufficiency Mitral Stenosis MVP Pulmonary edema Palpitations Thrombophlebitis Respiratory 493.90 493.91 466.0 162.9 786.2 496.0 492.8 487.1 511.0 482.9 415.2 515 465.9 Asthma Asthma with Status Bronchitis Cancer Lung Cough COPD Emphysema Influenza Pleurisy Pneumonia Pulmonary Embolism Pulmonary Fibrosis URI Hematologic 280.9 204.1 288.6 288.5 282.6 Anemia Iron def CLL Leukocytosis Leukocytopenia Sickle Cell Abdominal mass Abdominal pain Abdominal tenderness Appendicitis Carcinoma of colon Carcinoma of stomach Cholecystitis Colitis irritable bowel Colitis ulcerative Constipation Diarrhea Diverticulitis Diverticulosis Dypepsia Esophagitis Gastritis GERD GI bleed Hemorrhoids Melena Pancreatitis Rectal bleed Vomiting Nausea Head Neck Genitourinary 626.0 600.0 585.9 595.0 625.3 788.1 604.99 599.70 627.2 788.4 627.1 601.0 590.1 625.6 599.0 Arthritis DJD Arthritis Rheumatoid Back pain Baker's Cyst Bursitis Degenerative disc disease Carpal Tunnel Cervical strain Costochondritis Gout Muscle spasm Osteoporosis Post Traumatic pain Sprain ankle Sprain lumbosacral Spinal Stenosis Tendonitis Tenosynovitis Amenorrhea BPH CKD Cystitis acute Dysmenorrhea Dysuria Epididymitis Hematuria Menopause Nocturia Postmenopausal bleeding Prostatitis Pyelonephritis Stress incontinence UTI 477.0 366.9 372.30 918.1 780.4 784.1 784.0 346.9 784.49 380.4 464.0 380.10 461.9 477.9 473.9 373.11 388.32 463 474.0 780.4 Allergic Rhinitis Cataract Conjunctivitis Corneal Abrasion Dizziness Epistaxis Headache Headache Migraine Hoarseness Impacted cerumen Laryngitis Ottitis externa Sinusitis Acute Sinusitis Allergic Sinusitis Chronic Stye Tinnitus Tonsillitis Acute Tonsillitis Chronic Vertigo Outpatient Level 2 Level 3 Level 4 Level 5 HPI 1-3 1-3 ≥4 ≥4 ROS 0 1-3 3-8 ≥9 PFSHx 0 1 1-3 3 Exam 1-5 6-12 ≥12 20-30 Diagnosis 1 2 systemic systemic Severity Minimal Low Moderate High risk Complexity Simple Low Moderate High Abrasion Burn Cancer skin Cellulitis Contusion Dermatitis Eczema Herpes Zoster Hives Lipoma Paronychia finger Paronychia toe Pilonidal Cyst Psoriasis Sunburn Eczema Metabolic 331.0 300.00 311 250.03 250.02 276.5 780.7 272.4 244.9 780.52 278.01 Alzheimer's Anxiety Depression DM insulin DM noninsulin Dehydration Fatigue weakness Hyperlipidemia Hypothyroid Insomnia Obesity Neuro 781.20 332.00 724.3 780.30 436 431 438 780.2 435.9 781.0 Ataxia Parkinson's Sciatica Seizure Stroke embolic Stroke hemorrhagic Stroke old Syncope TIA Tremor QUIT SMOKING NOW Monitor your smoking, count the number of cigarettes you smoke each hour of the day: TIME MON TUE WED THU FRI SAT SUN What are your triggers? 1 AM 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 NOON 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 10 PM 11 PM 12 AM How to Quit: • Pre-Contemplation: You think there is no need to stop just now. • Contemplation: You start to think about quitting; list your reasons and benefits. • Action: You set a quit date and prepare yourself..... • Maintenance: Every day look in mirror and say, “I am a NON-SMOKER.” Why do you smoke? Here are five reasons people smoke and substitutions you can try. • Stimulation: start an exercise program, chew gum, start a healthy diet. • Handling: buy a knickknack to fiddle with. • Habit: separate smoking from everything you do: driving, food/drink, reading, watching TV, listening to music, etc. Prescription medication can help the habit. • Relaxer: start a new hobby, pick up a new book to read, 20 minute daily walks. • Addiction: nicotine patches, gum, sprays, acupuncture, hypnosis help the addiction. Try sniffing lemon peels when you have the urge to smoke. copyright © Medical Record Relief 1998 www.isbi.org Prepare yourself and your environment before your quit date 1. Don’t carry smoking material with you. 2. Assign your smoking areas and fumigate your non smoking areas. 3. Find an old chair where you must sit, smoke, and do nothing else. Place a glass jar in plain site to keep all your butts and ashes for one week. 4. When you quit throw out the chair and after one year throw out the jar and send me a note. 5. For each pack you buy put the same amount of money in a jar next to the jar with the butts. After you quit continue to add the cigarette money for one year. 6. If you stay off cigarettes spend the money on yourself, if you restart donate it to American Cancer Society or American Lung Association. 7. Buy only one pack at a time and a different brand every time. 8. Inhale less deeply or put a pinhole in the filter of each cigarette. 9. Mark the cigarette half way and smoke to the mark. 10. Chew gum, a straw, lollipop, toothpick, or breath mints. 11. Throw out the first five cigarettes from every pack just when you open it. 12. Carry a container for your butts and ashes. Take a whiff before you light up. 13. Scream internally “STOP IN _____ DAYS!!!” before you light up. 14. Throw out the remaining cigarettes and smoke a different brand every day. 15. Smoke exactly on the hour. If you miss it you must wait to the next hour. Step 1: Set your quit date at least 7 but not more than 21 days from now. Sometimes a buddy system, quitting with a friend, is helpful. Ultimately it’s up to you alone. Step 2: Monitor your smoking for 3-7 days. Mark the chart when you smoke. Under triggers, list what you were doing or where you were while smoking. Step 3: Chose from the suggestions above and start tapering over the remaining days to your quit date. You must include the following up to your quit date. 1. 2. 3. 4. 5. Delay your first cigarette of the day. Don’t smoke with any of the triggers. Assign a smoking area. Buy only one pack at a time. Always buy a different brand. Step 4: Quit on your quit date and reward yourself with a non-smoking night out. For the first few weeks avoid all smoking locations and hangouts. Look in the mirror every morning and say: “I AM A NON SMOKER” Remember.... Once you quit you can NEVER have another cigarette, and you will feel better today than yesterday, so QUIT SMOKING Name Address Ph: Fx: NOW... LOSE WEIGHT NOW Monitor your eating. Copy and keep a food diary. TIME What What are you doing along with eating? Where Change to a Healthy Lifestyle: • Pre-Contemplation: You think there is no need to change just now. • Contemplation: You start to think about change; list your reasons and benefits. • Action: You set a change date and prepare yourself..... • Maintenance: Every day look in mirror and say, “I’VE CHANGED.” Why do you eat? Here are five reasons people eat and substitutions you can try. • • • • • Stimulation: start your day with 3 minutes of exercise. Handling: buy a knickknack to fiddle with. Habit: separate eating from everything you do (driving, reading, watching TV). Relaxer: start a new hobby, pick up a new book to read, 20 minute daily walks. Addiction: designate one day a week for the food that prompts you to binge or has a domino affect. copyright © Medical Record Relief 1998 www.isbi.org Prepare yourself for change 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Start your day with 3 minutes of brisk exercise. Add 20 minutes of continuous exercise (walk or bike) 5 days a week. Jot down the minutes you exercise on a calendar. Keep a food diary for 5 days of what, when, where you eat and what activity is associated with eating. Assign your eating areas. Pick a place where you must sit, eat, and do nothing else. Find an eating buddy. Place a funny salt & pepper shaker or colorful place mat at your eating site. Take out your eating buddy ONLY when you are eating. Put it away when you are not. Visualize your eating buddy if you happen to be in a restaurant or before a snack. Chew your food longer. Leave something on your plate. Give yourself 3 guilt free days per month; choose them ahead of time. Have breakfast. Scream internally “I CAN SKIP IT” before you reach for that jelly donut. Throw out mayonnaise, ice cream and snacks. Buy only individual portions. If you eat a six pack of cookies you won’t feel as bad, as if you had eaten a family pack. 16. Eat at set times. If you miss your eating time have a snack and skip the meal. Step 1: Set your Healthy Lifestyle change date at least 7 days from now. Sometimes starting with a friend, is helpful. Ultimately it’s up to you alone. Step 2: Monitor your eating for 3-7 days to identify the types of foods you eat. Mark the chart when you eat. Under triggers, list what you were doing or where you were while eating. Step 3: Chose from the suggestions above to promote change over the remaining days to your Healthy Lifestyle change date. You must include the following up to your Healthy Lifestyle date. 1. 2. 3. 4. Name Address Start your day with a 3 minute minimum of exercise. Don’t eat with any of the triggers. Assign an eating area. Buy only individual portions of high calorie foods. Ph: Fx: Step 4: Start on your Healthy Lifestyle date and reward yourself with a Healthy Lifestyle night out. . Look in the mirror every morning and say: “I’VE CHANGED” Remember.... Once you change to a healthy lifestyle you will feel better and begin to loose weight sensibly! Height inches 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 Men 105 110 115 120 125 130 135 140 145 160 165 170 175 180 185 Women 100 104 108 112 116 120 124 128 132 136 140 144 148 152 156 Minimum Weights BMI of 24 125 130 140 150 160 Maximum Healthy Weights 170 180 190 Home Health Care Documentation Form for MEDICARE PATIENTS ONLY Patient Home Care Provider/ID Initial Plans Supervision Phone Call ICD-9 Verbal Orders DOB Results SSN Treatment Change Admit DC Date 99495 99496 Patient Home Care Provider/ID Initial Plans Supervision Phone Call ICD-9 Verbal Orders DOB Results SSN Treatment Change Admit DC Date 99495 99496 Name Address Ph: Minutes to complete Fx: Initial Care Plan 15 Phone calls 5 Supervision Care Plan 10 Orders 5 Review Results 5 Treatment change 5 G0180-G0181-G0182 Must be documented in office record ≥ 30 min per month 99495 transition codes need 1 INPERSON VISIT day 8-14 Signature Date 99496 transition VISIT within 7 days of DC copyright © Medical Record Relief 1998 www.isbi.org Face to Face Encounter Documentation Patient Name: ________________________________ DOB: __________ I certify that this patient is under my care and that I, a treating physician in the hospital, a nurse practitioner or physician’s assistant working with me, had a face to face encounter that meets the physician face-to-face encounter requirements with this patient on: ____/____ / 20____ The encounter with the patient was in whole, or in part, for the following medical condition which is the reason home health care is required: ____________________________________________________________________ On the basis of clinical findings and as a licensed physician I certify the following services are medically necessary and began within the last 30 days or shall begin within the next 90 days: _______Skilled Nursing _______Physical Therapy _______Speech/language Therapy _______Occupational Therapy Clinical findings support the need for the requested services because the patient: has a wound had surgery during the last hospitalization is SOB with minimal exertion has focal weakness/paralysis is physically/neurologically impaired requires assistance for administration or stabilization of medication is bed bound requires rehabilitation program by trained professional is chair bound uses an assistive device requires nutritional support would experience a considerable taxing effort upon leaving their residence for medical care other______________________________________________________________ I will follow this patient. Physician Signature:___________________________________ Date: _____________ Printed Name:_______________________________Fax: _________________ Address:_________________________________________Phone: _________________ Billing for home health visits requires a face to face exam 30 days prior or within 90 days of initiating home health services. Retention of the Medical Record It is a good practice for all aptients, both adults and minors, to keep the Medical Record for 10 years from the last patient encounter - There are four exemptions where the records should be kept permanently. • Records of an individual with permanent disabilities or a legal disability • Immunization records • Records of occupational exposure • Records involved in a malpractice claim [Permanently has been defined as long as the physician has a license to practice medicine, PLUS the applicable statute of limitations period.] Medical Record Fees (For persons other than patients) Patients may NOT BE CHARGED HANDLING FEES PER HIPAA but you may charge resonable cost-based fees: paper, copycosts, postage and staff time. Illinois formula for calculating medical record fees: $24.44 handling fee PLUS $0.92 each for pages 1-25, $0.61 each for pages 26-50, $0.31 each for pages 51 to end; PLUS actual postage. Electronic records retrieved from a scanning, digital imaging, electronic information or other digital format in an electronic document may charge 50% of the per page fee. No fee may be charged for the storage media such as a CD Rom. +Reasonable cost for duplication may be charged for copies of record information that cannot be duplicated on a copy machine. +Insurance company contracts or policies may prohibit or limit billing for records. Medicare and Medicaid do not pay for records. Workers compensation only authorizes a subpoena fee of $20. IMMUNIZATION • INJECTION FORM Name:____________________________________ DOB:____________ AGE:_________ History of: Cancer:_____ TB:_____ Egg Allergy:______ Asthma:_____ LIver problem:______ Healthcare worker:______ Allergy to Immunization:_____ COPD:_____ Caretaker:______ Injection of: H1N1 Flu:_________ PPD:_____ TD:_____ Hep B1:______ Injection site: Seasonal Flu:_________ DPT:_____ Hep B2:______ Right_____ Date Given:_________ Pneumovax:_________ MMR:_____ Other:_____________ Hep B3:______ Left_____ Arm Thigh Hip ____________ Date Read:_________ Lot#:____________________________________ Lot#:____________________________________ Lot#:____________________________________ Name Address Ph: Fx: Lot#:____________________________________ Signature:_________________________ MD DO RN PA NP MA Medicare Documentation for Diabetic Supplies Name Address Ph: Fx: Patient:_____________________________ Diabetic: Type I Type II Treated with: Age at onset: Diet Oral Medication: Injections: Basal Insulin Insulin pump: Yes 21-40 41-64 ≥65 Medication Metformin TZD Short acting insulin DPP-4 Inhibitor 70/30 Insulin Byetta/Victoza/Bydureon No End organ affected: Vision Prognosis: Poor Physical Limitations: None Cardiac Testing frequency ordered: 2-5/Week poor control Neuropathy Renal PVD Requires assistance with medication Rx Date:___________ For Diabetes supplies: Patient has: <21 Exercise Glipizide/Glyburide Good DOB:______________ Test Strips Daily X 1 good control X2 Lancets X3 Meter 4+ widely fluctuating readings loss of consciousness Office Visit Home BS range Date AIC This patient has been under my care since____________and was last seen in the office on __________. The information as listed above is certified to be summarized from the identified Patient’s Record; completed and signed by me on ____________. _____________________________ Signature _________________ ____________________ NPI Licensee Approximate visit times Office visits Hx Ex Dx New F F S 99201 F F L E E S D D M D D L C C H TIme Established Inpatient visits New 99211 5 99212 10 99213 15 99202 Established Hx Ex Dx 99231 F F L 20 99214 25 99203 30 99215 99232 E E M D D L D D H 99222 C C M 99223 C C H 99221 35 99233 40 C C M 99204 45 50 C C H 99205 60 70 Home visits Hx Ex Dx New TIme Established Nursing Facility New Established Hx Ex Dx 99307 F F S 99308 E E L D D L D D M C C M C C H C C H Hx Ex F=Focused 1-3 1-5 5 10 F F S F F S E E L E E L 99347 15 99341 20 99348 25 99342 30 99304 35 D D M D D M 99343 99349 C C M 99344 C C H 99345 40 99309 99305 45 50 99350 99310 99306 60 Hx = History 70 Dx = Diagnosis or 75 Ex = Exam management options S=Straightforward 1 diagnosis/no data/ minimal risk L=Low complexity 1 diagnosis/limited data/low complication risk E=Expanded 4-8 6-11 M=Moderate complexity ≥2 diagnosis/moderate data & risk D=Detailed H=High complexity systemic/extensive data/high complication risk F=Focused Exam CC HPI C=Comprehensive ROS PFSH 1-5 Yes 1-3 None None E=Expanded 6-11 Yes 1-3 Pertinent None D=Detailed 12-18 Yes ≥4 2-9 Pertinent ≥19 Yes ≥4 Complete Complete C=Comprehensive ≥9 12-18 ≥9 ≥19 Medical Records Relief PATIENT REGISTRATION: allows for proper billing and conforms to the Personal Social History requirement. Address, phone numbers, and insurance carrier should be confirmed as accurate at each visit. You may ask your patients to update the registration form yearly. Keep the original and and the latest update in the chart. COMPREHENSIVE REVIEW OF SYSTEMS: can be obtained by your staff, the patient, or yourself. If your staff ask the questions be sure to check the box “Reviewed by physician” at the bottom of the page. Check the box related to the question asked. If it's positive then circle the item and explain it in the margin, and do the same in the initial H&P. If you are using the progress note forms, slash through negative symptoms and circle the positive ones. If necessary explain further in the HPI section. You need not go back and make changes in the Comprehensive ROS for each new visit simply circle new or persistent symptoms in each progress note. The Family History may be completed as the example to the right. Example: The brother had diabetes and cancer, mom had diabetes. No Family History of stroke. Diabetes Cancer Stroke brother sister mother father grandparent brother sister mother father grandparent brother sister mother father grandparent PREVENTION: is an overview if what should be asked at different ages. This form is based on the US and Canadian Task Force Prevention guidelines. When you discuss or suggest a test , mark a slash through the test offered or discussed. If a test was completed then circle it on the form or in some cases, fill in the year in the space provided. Your progress note should include more detail of the topic or exam. PROBLEM LIST: You may choose to list the diagnosis of each visit, significant lab or X-ray studies, surgeries and or hospitalizations. Think if this as a “snapshot” of your patient’s medical history. Some patients keep a copy of this sheet. We always update the patient Fold Out Wallet Card with the same information that is on the problem list. List each medication prescribed. Once its discontinued draw a single line through it. If there were any ill effects be sure it was documented in your progress note or add the side effect to the problem list. Ask about immunizations. Keep up to date on tetanus, influenza, pneumonia, and HBV when appropriate. You may choose to fill in the year, month/year, or the exact date a vaccine or screening test was done. The exact date should still be in your progress note. You can add screening tests to the bottom of the page if you want. Check the appropriate box for the patient’s prescription plan 30 or 90 days fill. HISTORY AND PHYSICAL & PROGRESS NOTES: The medical visit generally includes these 6 components: 1. CC: is the chief complaint. 2. HPI: is the History of the Present Illness which may include location, quality, severity, duration, timing, context, modifying factors, associated symptoms of the chief complaint. 3. ROS: review of systems includes questions about constitutional, gastrointestinal, respiratory, genitourinary, neuromuscular, and cardiovascular symptoms. 4. PFSH: is the past, family and social history 5. Examination: where the body is divided into 13 regions. Each region has from 2 to 8 elements. On the forms a region is in bold letters, the elements are listed below each respective region, which may include indented items. The indented items are partial elements and must be included with the element above them for this element to be counted. For example: examination of the Nose is a single element and must include examination of the septum, mucosa, and turbinates. 6. Diagnosis: here you list your diagnosis as well as give your synthesis of any lab data and what you plan to do (tests ordered, Rx written, referred to therapy or another physician, follow-up care). First document the patients CC and History of the Present Illness using the location, quality, severity, duration, timing, context, modifying factors, associated symptoms of the CC. As an alternative you can describe the status of at least 3 chronic or inactive conditions if there is no chief complaint. For ROS circle the positives and slash through any that you ask while you are taking the history. Positives may be expanded in the appropriate space. Use the same slash-circle method for the examination but here you must explain the positive in the space provided. During a follow-up visit if you ask any PFSH questions document the changes such as; “retired” or “quit smoking”. If there are none, write “unchanged or ø” in the space below PFSH. You could also document PFSH changes in the note. PFSH notation is only required for detailed or comprehensive level exams. When you review the medications; the names, doses and ask about side effects circle the “YES” and be sure to enter changes in the MEDICATION section on the problem list page. Do this also if you review the Problem List. Review of the problem list and medications this can fulfill the PFSH requirement for a higher coded visit. You can add a diagnosis for the visit to the problem list if you feel it is significant or will have some effect on the patient in the future. We often list an injury date and the return to work date on the Problem List so it can be referenced later if needed. Should you need more than the 40-50 entries for problems or medication changes add a second problem list page. The examination portion of your note should be documented as follows. Check off any elements you examine or observe and are normal circle any abnormal findings. If the patient walks in normally check off “gait”. If they are using a cane circle “gait” and document “uses cane in L hand”. At least three constitutional (vital signs) need to be documented for a maximum credit of 2 elements or to qualify for a completed REGION. HOME HEALTH CARE FORMS: If you bill for home health care you must document the date corresponding to your supervision of the initial plans, orders, phone calls as well as a “Face to Face” contact with the patient (which can be done by you or another professional you have supervised or had contact with). Submit to Medicare once you have accrued 30 minutes of supervision. HOW TO CODE THE VISIT: • Minimal does not require a physician a supervised nurse or assistant may just take a BP or give an immunization. • Problem focused has a single diagnosis where the history (HPI) includes 1-3 questions (location, quality, severity, duration, timing, context, modifying factors, associated symptoms) about the chief complaint (CC) ; the exam will have 1 to 5 elements (Vitals, listen to heart, lungs, check for edema). • Expanded Problem has two diagnoses, you will ask 1-3 questions as well as pertinent review of systems; the exam will have 6-12 elements. • Detailed visit is usually a systemic illness that requires ≥4 questions in the HPI, 2-9 ROS questions, 1 PFSH, and 12 or more elements on the exam. • Comprehensive visit is for a severe illness or condition, requiring ≥4 questions in the HPI, ≥9 ROS questions, at least 2 PFSH, and 9 or more REGIONS where ≥ 30 elements are examined. Visit Type CC HPI ROS PFSH Exam Diagnosis Minimal YES 1-3 NO Problem Focused YES 1-3 NO NO NO NO NO 1-5 elements 1 Expanded Problem YES 1-3 Detailed YES ≥4 1-2 NO 6-12 elements 2 3-8 1 of 3 ≥12 elements Systemic Comprehensive YES ≥4 ≥9 ≥2 of 3 ≥30 elements Severe Form Abbreviations Abbreviation ADL BP CAD CC CN II-XII CV E-ENTM ENT GERD GI GU HTN HPI Musc Neuro Meaning Activities of daily living Blood pressure Coronary artery disease Chief complaint Cranial nerves II to XII Cardiovascular Eyes-Ears nose throat mouth ears nose throat Gastroesophageal reflux disease Gastrointestinal Genitourinary Hypertension History of the present illness Musculoskeletal Neurologic Abbreviation P•P•S•Y palates PERRLA PFSH PMI PND Psych R=L Resp or R Rheum ROM ROS S•G•B Temp or T TM EAC Vac Meaning Orientation to person place season year hard and soft palates Pupils are equal round reactive to light and accommodation Past medical, family, and social history Position of Maximal intensity Paroxysmal nocturnal dyspnea Psychological Right equals left Respiratory Rheumatologic Range of motion Review of systems Straight gay bisexual Temperature Tympanic membrane External auditory canal Vaccine HISTORY Documentation Guidelines (DG) for Evaluation and Management (E/M) Services were produced by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA). The next 2 pages is a summary of the 52 page AMA document. First approved in May 1997 and updated in November 1997, these guidelines were developed so the medical record will include the reason for the visit, relevant history, physical examination findings, and diagnostic results. From this information, a clinical impression and a plan for care can be formulated. So far it is a typical day in the office. But, Medicare identified specific elements of the HISTORY, EXAMINATION, and DECISION-MAKING process which are awarded points that can be tallied. You are required to select a code that correlates to the number of points documented in your history, exam and decision making that took place during the visit. If someone comes in for an head cold, you will most likely examine them and diagnose a head cold, and then suggest a treatment. You can’t code a high-level visit even if you do an extensive examination. It’s just an head cold! If the patient comes in for a head cold and you detect a new hemiparesis, you may still list a head cold in the diagnosis. But, the additional history, exam, and decisions you make to test and treat the latter patient, oblige you to code a higher level for the visit. Below is an outline of what is expected when your code is compared to your chart. There are four types of medical history. You must code the visit to reflect the type of history you take: CC HPI ROS PFSH Problem Focused History YES BRIEF 1-3 NO NO Expanded Problem YES BRIEF 1-3 PERTINENT NO Detailed YES EXTENDED ≥4 EXTENDED 2-9 PERTINENT Comprehensive YES EXTENDED ≥4 COMPLETE COMPLETE Problem-focused Expanded Problem-focused Detailed Comprehensive Each of these types of history must contain the: Chief Complaint (CC). Reason for the visit in the patient’s words. History of the Present Illness (HPI). A chronological description incorporating the following eight elements; location, quality, severity, duration, timing, context, modifying factors, and associated symptoms of the patient’s illness. A BRIEF HPI includes 1-3 elements An EXTENDED HPI should contain ≥ 4 elements or can review the status of 3 chronic conditions The history can incorporate: Review of Systems (ROS). Inventory of these 13 body systems: constitutional, eyes, ears-nose-mouth-throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, hematologic/lymphatic, allergic/immunologic. PERTINENT contains responses for the affected system EXTENDED contains responses for 2-9 systems COMPLETE contains responses for ≥ 10 systems Past history, family history, social history (PFSH). This should include: 1) illnesses, operations, injuries and treatments the patient has experienced; 2) any significant medical events or hereditary illness in the patient’s family; 3) past or current activities of the patient. PERTINENT contains one of the three COMPLETE contains at least two The CC, ROS and PFSH may be listed as separate elements or included in the HPI. The ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if the physician reviews and updates the previous information. Your staff or the patient may complete any form for ROS or PFSH, but you must document a confirmation and note any changes to the information recorded by others. EXAMINATION The examination can concentrate on a single region, more than one region or take the form of a general multi-system examination. There are four types of medical examinations. You must code the visit to reflect the type of exam you conducted: Problem Focused - limited exam of affected region. Expanded Problem Focused - limited exam of affected region and additional, related region(s). Detailed - extended exam of affected region and additional related region(s). Comprehensive - general multi-system exam or complete single region and related region(s). Examination Problem Focused Single system Multi-system 1-5 elements 1-5 elements Expanded Problem 6-12 elements 6-12 elements Detailed ≥ 12 elements ≥ 6 regions with ≥ 2 elements per system Comprehensive ≥30 elements ≥ 9 regions with all elements per system There are 14 regions for examination: Organ system Respiratory Constitutional: BP, pulse, temp, RR, height, weight, appearance Region Respiratory Effort Head and Face: inspection, palpation, salivary glands Breath sounds Eyes: visual acuity, fields, conjunctivae, lids, pupils Percussion Ears, Nose, Mouth, Throat: EAC’s, TM’s, mucosas TM EAC right Elements TM EAC left Hearing R = L Fremitus Neck: palpation, thyroid ENT • Mouth Ears external Nose Respiratory: respiratory effort, percussion, palpation, auscultation mucosa Cardiovascular: palpation, auscultation, exam of pulses septum Chest: inspection and palpation of breasts turbinates Gastrointestinal: palpation of liver , spleen, masses, exam for tenderness Genitourinary: (female or male) Hematologic • Lymphatic • Immunologic Musculoskeletal: range of motion , muscle strength and tone Skin: inspection, palpation Neurologic/Psychiatric: mental status, cranial nerves, reflexes, sensation • When a finding is abnormal it must be described: Simply identifying it as abnormal does not count! • A simple notation of normal is accepted for normal or negative findings. MEDICAL DECISIONS These are the four types of medical decisions you make every day: Straightforward - single diagnosis, no labs, minimal risk. (tinea coporis or a cold or an insect bite ) Low Complexity - two problems or stable chronic problem, limited testing, low risk. (controlled HTN and allergic rhinitis) Moderate Complexity - single acute systemic illness or chronic illness(es) with exacerbation. (colitis or pneumonia) High Complexity - single acute illness threatening function or chronic illness(es) with severe exacerbation. (TIA, sensory loss, MI, respiratory distress) The physician could be slighted on scoring even after Decision making completing a comprehensive exam if the decision Straightforward making level does not correlate with the possible Low complexity diagnosis. Document what you are thinking! Moderate complexity High complexity Diagnose & Manage Data Risk minimal none minimal limited limited low multiple moderate moderate extensive extensive high Pocket summary coding prompts Office Visit Level 2 Level 3 Level 4 Level 5 Focused Expanded Detailed Compreh HPI 1-3 1-3 ≥4 ≥4 ROS 0 Pertinent 2-9 ≥9 Exam 1-5 element 6-12 element ≥12 element ≥30 element DX 1 2 systemic severe Hospital Visit HPI ROS Exam 99221 Improving 1-3 1-3 ≥6 99222 Stable ≥4 3-8 ≥12 99223 Unstable ≥4 ≥9 ≥20 2 systemic severe DX Sweats chills fevers weight appetite sleep fatigue Vision headache dizzy ears throat sinus voice PND palpitations edema chest pain pressure SOB DOE orthopnea wheezing cough sputum Nausea vomiting dyspepsia pain change in BM Nocturia dysuria urgency frequency libido Joint muscle pain stiffness weakness cramps Reviewed Medication List Yes Reviewed Problem List Eyes Neck GU GI Conjunctivae Lids PERRLA Fundi lens disc Palpation Thyroid Scrotum Penis Prostate Fem Genitals Urethra Bladder Cervix Uterus Adnexa Scars Bowel sounds Consistency Tender • Mass Liver • spleen Hernia Ano-rectal Occult blood Skin Gait Digits nails Upper Extrem ROM Strength • Tone Lower Extrem ROM Strength • Tone ENT- Mouth Ears external TM EAC right TM EAC left Hearing R = L Nose mucosa septum turbinates Teeth • gums lips Oropharynx mucosa•palates tongue•tonsils glands•pharynx Resp Effort Breath sounds Percussion Fremitus CV Palpate PMI thrill Heart sounds No murmur Carotids Aorta Femorals Pedal pulses Varicose veins Edema Inspection Palpation Lymph Neck Axillae Groin Neuro CN II-XII DTR Inspect breasts Sensation Palpate breasts Cerebellar Chest Counseling Advised on Exercise Advised on Medications and side effects Yes Mus/Skel Psych Year Season Affect 3 step command Advised on Diet Discussed tests Listed are 58 elements. Non-indented elements equal 1 point. ALL indented elements must be documented for 1 point. Vital Signs havel 3 value points. Inpatient Outpatient Level 2 Level 3 Level 4 Level 5 Level 1 Level 2 Level 3 1-3 1-3 ≥4 ≥4 HPI 1-3 ≥4 ≥4 0 1-3 3-8 ≥9 ROS 1-3 3-8 ≥9 1-5 6-12 ≥12 ≥30 Exam ≥6 ≥12 ≥20 1 2 systemic systemic Diagnosis 1 ≥2 systemic Minimal Low Moderate High risk Severity Improving Unchanged Worse Simple Low Moderate High Complexity Low Moderate High Office Visit Level 2 Level 3 Level 4 Level 5 Focused Expanded Detailed Compreh HPI 1-3 1-3 ≥4 ≥4 ROS 0 Pertinent 2-9 ≥9 Exam 1-5 element ≥6 element ≥12 element ≥18 element DX 1 2 systemic severe Hospital Visit HPI ROS Exam DX 99221 Improving 1-3 1-3 ≥6 99222 Stable ≥4 3-8 ≥12 99223 Unstable ≥4 ≥9 ≥20 2 systemic severe Listed are 13 regions and 58 elements. Non-indented elements are 1 point. ALL indented elements must be done for 1 point. Eyes Neck GU GI Conjunctivae Lids PERRLA Fundi lens disc Palpation Thyroid Scrotum Penis Prostate Fem Genitals Urethra Bladder Cervix Uterus Adnexa Scars Bowel sounds Consistency Tender • Mass Liver • spleen Hernia Ano-rectal Occult blood Skin Gait Digits nails Upper Extrem ROM Strength • Tone Lower Extrem ROM Strength • Tone ENT- Mouth Ears external TM EAC right TM EAC left Hearing R = L Nose mucosa septum turbinates Teeth • gums lips Oropharynx mucosa•palates tongue•tonsils glands•pharynx Counseling Resp Effort Breath sounds Percussion Fremitus CV Palpate PMI thrill Heart sounds No murmur Carotids Aorta Femorals Pedal pulses Varicose veins Edema Inspection Palpation Lymph Neck Axillae Groin Neuro CN II-XII DTR Inspect breasts Sensation Palpate breasts Cerebellar Chest Mus/Skel Psych Year Season Affect 3 step command Advised on Exercise Advised on Medications and side effects Advised on Diet Discussed tests DOCUMENTATION OF THE EXAMINATION Problem Focused -- a limited exam of the affected body area or organ system. Expanded Problem Focused -- a limited exam of the affected body area or organ system and related organ system(s). Detailed -- an extended exam of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive -- a general multi-system exam or complete examination of a single organ system. For purposes of examination, points are given for the following: Constitutional • Body Areas • CONSTITUTIONAL General appearance BP supine • sitting • standing Temp Pulse (regular irregular) Resp (regular irregular) BODY AREAS ORGAN SYSTEMS Head-Neck, including the face Cardiovascular Musculoskeletal Chest, including breasts and axillae Otolaryngologic Respiratory Abdomen, Genitalia, groin, buttocks Hematologic/Lymphatic Endocrine Each extremity Back, including spine Allergic/Immunologic Genitourinary Psychiatric Organ Systems Weight Height Ophthalmologic Neurologic Gastrointestinal Integumentary DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as gauged by: the number of possible diagnoses and/or the number of management options; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options. Low Complexity Medical Decision Making, the problem will (1) be of low severity, urgency and low risk of complications, (2) have a limited differential diagnosis with limited review of additional data, (3) have a straightforward diagnostic and/or therapeutic interventions, and a straightforward treatment plan. For the purpose of documentation two of these three elements must either meet or exceed the requirement for low complexity. Moderate Complexity Medical Decision Making, the problem(s) addressed will (1) be of moderate severity with a low to moderate risk of complications, (2) require review of a moderate amount of additional information with an extended differential diagnosis, (3) require complicated diagnostic and/or therapeutic intervention, and complicated treatment plan. For the purpose of documentation two of these elements must meet or exceed the requirement for moderate complexity. Highly Complex Medical Decision Making, the problem(s) addressed will (1) be of high severity with a high risk of complications and clinical deterioration, (2) require review of an extensive amount of additional information with an extensive differential diagnosis, (3) require highly complex multiple diagnostic and/or therapeutic interventions, with a highly complex treatment plan. For the purpose of documentation two of these three elements must either meet or exceed the requirement for highly complex medical decision making.
