Interstital
Lung Disease
Evaluation Medical
Note Template
The interstitial lung disease evaluation MedicalTemplate is suitable for any health care provider who may evaluate a patient with interstitial lung disease.
- E&M Documentation Template
- Digital Health Record
- Digital Signature Option
- Reminders
- Follow Up
- Referral
- Labs
- Therapeutic options
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Template updated 2/8/08 | Template Features
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ILD and the Healthcare System
Interstitial Lung Disease (ILD) is a diverse group of more than 200 diseases that cause progressive fibrosis (scarring) of lung tissue, which leads to chronic, progressive breathlessness and respiratory failure. The Pulmonary Fibrosis Foundation (www.pulmonaryfibrosis.org) estimates that more than 200,000 Americans have ILD, and nearly 40,000 Americans die each year from ILD.
ILD
includes
idiopathic pulmonary fibrosis (IPF), sarcoidosis, hypersensitivity
pneumonitis,
Nonspecific Interstitial Pneumonitis
(NSIP), Desquamative
Interstitial Pneumonitis (DIP),
Cryptogenic Organizing Pneumonia (COP, aka BOOP), medication induced
lung
disease, post-radiation fibrosis, and many other diseases.
The primary symptoms of ILD are nonspecific, such as non-productive cough and progressive breathlessness. These symptoms are seen in many other medical conditions such as asthma, heart failure, or chronic obstructive pulmonary disease (COPD). The lack of specificity of the presenting symptoms makes the identification of ILD challenging, particularly in individuals with known heart or lung disease. Early and accurate diagnosis of ILD is essential so that treatment options can be considered before extensive and permanent damage occurs, resulting in disabling breathlessness. While there is currently no proven, FDA-approved treatment for idiopathic pulmonary fibrosis, many forms of interstitial lung disease can be treated, if detected early in the disease process. Thus, having a low threshold for suspecting interstitial disease, and assessing a patient’s risk of developing pulmonary fibrosis by obtaining important historical information is critical to early diagnosis.
E & M Documentation Template
The interstitial lung disease evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.
- History
- Chief complaint
- History of present illness
- Past medical and surgical history
- Social history
- Family history
- Review of systems
- Examination
- Medical Decision Making
- Review of data (labs, tests, imaging, old records)
- Assessment and plan
- 1997
Documentation Guidelines for Evaluation and Management
Services
- 1995
Documentation Guidelines for Evaluation and Management
Services
Digital Health Record
The interstitial lung disease 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 interstitial lung disease evaluation 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.
Digital Signature Enabled
To learn more about Adobe PDF digital signatures, click here.
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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.
