Clinic H&P Medical Note Template
The clinic history and
H&P) MedicalTemplate is suitable for internal
medicine physicians, family practice physicians,
and other health care providers.
Licenses for standard 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, 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.
- 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
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
- A supervising
physician version is available for doctors that
work with physician extenders or residents
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 RecordThe 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.