Influenza Like Illness Evaluation Medical Note Template
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The Influenza Like Illness evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, pulmonologists, and other health care providers that evaluate patients with known or suspected H1N1 Influenza (Swine Flu) or seasonal influenza.
This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with an influenza like illness. It is suitable for use as a history and physical, consult note, or follow up note. |
Influenza Like Illness Medical Documentation Template |
Influenza in 2009-2010
The 2009-2010 influenza season has been marked by rapid spread of a novel H1N1 Influenza A virus (often referred to as “Swine Flu”). Identified in April 2009, H1N1 has been identified worldwide and is widespread in virtually every state in the United States as of the week ending October 17, 2009, according to the Centers for Disease Control and Prevention. In response to the rapid spread of this H1N1 virus, President Obama declared a national emergency on October 24, 2009.
Unlike seasonal Influenza A, the novel H1N1 Influenza A virus has affected primarily people under the age of 65. While a monovalent vaccine free of adjuvants has been created, it is not yet widely available. Groups targeted to receive the novel H1N1 Influenza A vaccine are
The unseasonably early and rapid spread of influenza has resulted in an 8-fold increase in the number of outpatient clinic visits for Influenza Like Illness, further straining health care resources. By week 40 of 2009, 8% of all outpatient visits were due to Influenza Like Illness, compared to 1% in years 2006-2008 during the same period (CDC).
E & M Documentation Template
The Influenza Like Illness evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new patient evaluation, consult, or follow up note.
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.
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History Click here to learn about History Documentation
- When
completed, this document is a comprehensive
(highest) level history as
defined in 1997 Guidelines for E&M Services.
- 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
- Prompters for
- Risk factors for H1N1 and seasonal influenza
- Treatment options for H1N1 and seasonal influenza
-
Examination Click here to learn about Physical Exam Documentation
- When
completed, this document is a comprehensive
(highest) level physical exam as
defined in 1997 Guidelines for E&M Services.
- General Multisystem Exam OR Respiratory System 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 Influenza Like Illness 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 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.
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.
