Clinic
H&P Medical Note Template The clinic
history and physical (clinic
H&P) MedicalTemplate is suitable for
internal medicine physicians, family practice physicians, and other
health care providers.
When
completed, and in conjunction with a supporting level of
medical decision making, the Clinic H&P MedicalTemplate meets or exceeds the
documentation requirements in the 1995 and 1997 Medicare
Guidelines for E&M services for the highest level of service.
How to use MedicalTemplates
Last
update 9/1/08
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E
& M
Documentation Template The clinic H&P
MedicalTemplate
contains prompters and space for all the required
elements for a
E&M encounter.
consult. 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 When
completed, represents a comprehensive (highest) level physical exam as
defined in 1997 Guidelines. General
Multisystem Exam Checkboxes
for pertinent negatives and common positive findings 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 Medical Documentation
References and Resources Back
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Digital Health Record The clinic H&P 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
clinic
H&P 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.
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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.
