1. health and fitness
2. disease
3. headaches and migraines

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
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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
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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
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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.