Chest Pain Evaluation Medical Note Template
|
The chest pain evaluation
MedicalTemplate
is suitable for any health care
provider that manages patients with chest pain
in inpatient and
ambulatory settings. Licenses for MedicalTemplates
start at $99 for a single user. Volume
discounts are available.
When completed, and in conjunction with a supporting level of medical decision making, the chest pain evaluation MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service for outpatient services. |
Chest Pain Evaluation |
The American Heart Association reports that 8.9 Million people experience angina (cardiac chest pain) each year, and that 400,000 new cases of angina are diagnosed each year. Angina is the most common symptom of heart disease, which is the leading cause of death for men and women in the United States. The CDC reports that 29% of the deaths in 2002 (the most recent year with published statistics) were due to heart disease. More women than men died of heart disease in 2002.
Because of the prevalence and significance of cardiac related chest pain, a comprehensive cardiac evaluation forms the cornerstone of any chest pain evaluation. However, other causes of chest pain such as pulmonary embolisim, pneumonia, pericarditis, esophagitis, and aortic dissection must also be considered.
E & M Documentation Template
The chest pain evaluation MedicalTemplate contains prompters and space for all the required elements for a new or subsequent inpatient or outpatient E&M encounter.
When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.
-
History Click here to learn about History Documentation
- When
completed, this document is a comprehensive
(highest)
level
history as
defined in 1997 Guidelines for E&M Services.
- Chief complaint
- History of present illness
- Past medical and surgical history
- Social history
- Risk
factors for disease (occupational exposures,
smoking, and
others)
- Family history
- Review of systems
- Yes/No checkboxes for clear and complete documentation
-
Examination Click here to learn about Physical Exam Documentation
- When
completed, this document is a comprehensive
(highest)
level
physical
exam as
defined in 1997 Guidelines for E&M Services.
- General Multisystem Exam OR Respiratory System Exam
- Checkboxes
for pertinent negatives and common positive findings
-
Medical Decision Making Click here to learn about MDM Documentation
- Full
page
for adequate space with complex patients
- Easy Documentation with checkboxes
- Review of labs, tests, imaging, old records
- Coordination of care
- Common diagnostic and therapeutic options
- Assessment and plan
Medical Documentation References and Resources
- 1997
Documentation
Guidelines
for
Evaluation
and
Management
Services
- 1995
Documentation
Guidelines
for
Evaluation
and
Management
Services
- HGSA
Documentation
worksheet
- Trailblazer
Health
documentation
worksheet
(for DE,
MD, TX, VA, or the DC)
- Medicare
Audit
and/or
Coding
Worksheet
- TrailBlazer
Medicare
Audit
and/or
Coding
Worksheet
Digital Health Record
The chest pain evaluation MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes. This allows information to be typed in or pasted from other applications to fill out the template.Filled MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.
To learn more about how MedicalTemplates can be used as a digital health record, click here.
MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader. With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.
