Clinic H&P Medical Note Template
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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, 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. |
Clinic History and Physical MedicalTemplate |
E & M Documentation Template
The Clinic H&P MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new patient evaluation or outpatient consult.
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History Click here to learn about History Documentation
- 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, represents a comprehensive (highest) level physical exam as
defined in 1997 Guidelines.
- General Multisystem 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 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 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.
