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

1.        Pregnant women

2.       People who live with or work with infants less than 6 months of age

3.       Health care and emergency service personnel

4.       Children and young adults ages 6 months-24 years

5.       Adults aged 25-64 years with medical conditions that predispose them to influenza-related complications

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.

• 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

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

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.