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Last Modified 1/5/2009

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.

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    Read this document on Scribd: Clinic History and Physical MedicalTemplate

    Ambulatory Evaluation Review of Systems Yes Constitution Fatigue Malaise Fever or chills Appetite changes Eyes Vision changes New pain Scotomas ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Urinary changes Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rashes Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Patient Name Chief complaint/Reason for consult No Patient DOB Referring MD History of Present Illness ‰Patient is Nonverbal. History obtained from ‰Family ‰Medical records Allergies and Medications ‰Allergy List reviewed Medications ‰No drug allergies ‰No food allergies ‰Medications reviewed Social History ‰Medications reconciled with Nursing Home or Hospital discharge Info œ46 Risk factors ‰Domestic violence ‰Tattoos ‰High risk sexual behavior ‰Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics ‰Benzodiazepines ‰Never Smoker ‰Chews tobacco ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit ‰Patient is unwilling to quit ‰Patient willing to consider quitting ‰Patient quit, but resumed smoking ‰Patient willing to quit within 1 month Patient has tried ‰Nicotine replacement ‰Buproprion or nortriptyline ‰Nicotine receptor blockade ‰Asthma ‰CHF ‰COPD ‰Coronary Artery Dis ‰Premature Onset ‰Malignancy, specify Family Medical History ‰Pancreatitis ‰Peripheral Artery Disease ‰Renal Dysfunction ‰Thrombotic disorder ‰Thyroid Disease Daily, occasional and ex-smokers are more likely to be hazardous drinkers 1 “drink” is equal to 12 oz. can of beer, 1.5 oz. liquor (80 proof) or 5 oz wine ‰Alcohol use _____ Drinks per ‰day ‰week Definitions of Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day Past Medical and Surgical History Allergy/Immunology Sinus problems Recurrent infections Psychologic Mood changes Agitation Psychosis ‰Asthma ‰Hypertension ‰Adrenal dysfunction ‰Inflammatory Bowel Disease ‰Arthritis ‰Irritable Bowel Syndrome ‰Cerebral Artery Dis ‰Myocardial Infarction ‰CHF ‰Neuromuscular weakness ‰COPD ‰Pancreatitis ‰Coronary Artery Dis ‰Peripheral Artery Disease ‰Cystic Fibrosis ‰Renal dysfunction ‰Diabetes ‰1 ‰2 ‰Thrombotic disease ‰GERD ‰Thyroid disease, hyper ‰Gout ‰Thyroid disease, hypo ‰Hepatic dysfunction ‰Seizure disorder ‰HIV/AIDS ‰Sleep Apnea ‰CPAP ‰BiPAP ‰Chemotherapy ‰Colonoscopy ‰ECHO/Stress test ‰Immunosuppressive therapy ‰Mammogram ‰Organ failure ‰PFTs ‰Pap Smear ‰Prior intubations ‰Radiation exposure ‰Sleep study ‰Steroid use, chronic ‰Strokes ‰CABG ‰Splenectomy ‰Organ transplant ‰Other Surgeries ‰Malignancy ‰Adrenal ‰Colon ‰Melanoma ‰Renal cell ‰Thyroid ‰Breast ‰Lung ‰Prostate ‰Testicular Vaccines ‰Flu ‰Pneumo ‰Tetanus ‰Papilloma ‰Varicella ‰Pertussis ‰Hepatitis ‰BCG İMB and RR 2006-2008 Revised1Sep08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Ambulatory Evaluation Prior Diagnostic Data \____/ / \ ____ / ____ / ____ / \ \ \ Patient Name Exam Patient DOB ‰Checked box indicates findings are within normal limits OR stated abnormality is present % General ‰Alert Vitals T Prate ‰Reg ‰Irreg R BP Sats ‰ Conjunctivae ‰Pupils ‰Discs Eye ENT ‰TM ‰Pharynx ‰Dentition ‰Nasal ‰External ears ‰Hearing Neck ‰Exam ‰Thyroid Resp ‰Auscultation ‰Effort ‰Percussion ‰Palpation CV ‰Auscultation ‰Palpation ‰Edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses Breasts ‰ Inspection ‰Palpation / \ GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac \ / GU ‰Scrotum ‰Penis ‰Prostate ‰Urethra _ __ I I __ _ Gyn ‰External ‰Bladder ‰Cervix ‰Uterus ‰Adnexa \ / I \ / Lymph ‰Neck ‰Axilla ‰Groin ‰Other \_/ I \_/ Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength I Skin ‰Inspection ‰Palpation / \ Neuro ‰CN ‰DTR ‰Sensation / \ Psych ‰Affect ‰Orientation ‰Insight ‰Memory \ / Additional Findings _ _\ /_ _ This patient may benefit from Impression Code Status ‰Patient is a FULL CODE ‰DO NOT ATTEMPT RESUSCITATION Schedule ‰Influenza vaccine ‰Pneumococcal vaccine ‰Colonoscopy ‰Mammogram ‰Cardiac Stress Test ‰Echocardiogram ‰Other ‰Completed advance health care directives in chart œ47 HCPOA is ‰Labs ‰Consult ‰Follow Up Signature cc Data Reviewed Care Coordinated With ‰ ER Notes ‰ Old Chart ‰EMS Note ‰ECG ‰Nursing Notes & Vitals log ‰ Labs ‰ X Rays ‰MRI ‰US ‰CT ‰ER MD ‰HCPOA ‰Primary Care MD ‰Case Management ‰Social Worker ‰Pharmacy İMB and RR 2006-2008 Revised1Sep08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
    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.
    • 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

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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.