The lung mass evaluation MedicalTemplate is suitable for any health care provider that evaluates patients with lung masses and potential lung cancer.     When completed, and in conjunction with a supporting level of medical decision making, the lung mass evaluation MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service for outpatient services. How to use MedicalTemplates

Lung Mass Evaluation

Lung Masses

The discovery of a lung mass provokes great fear, because this discovery may be the first sign of lung cancer or other cancer. Because of the risk of cancer, a thorough and timely evaluation of a lung mass is imperative.

The Centers for Disease Control and Prevention states, ”More people die from lung cancer than any other type of cancer. This is true for both men and women. In 2003 (the most recent year for which statistics are currently available), lung cancer accounted for more deaths than breast cancer, prostate cancer, and colon cancer combined.”

In 2003 nearly 200,000 people were diagnosed with lung cancer. In that same year, 160,000 died from lung cancer. The treatment for lung cancer is not very effective, unless detected and treated in the earliest, often asymptomatic, stages.

Not all lung masses are due to cancer. Lung masses can develop as a result of infection, primarily tuberculous and fungal infections. Other disease processes associated with lung masses include rheumatoid arthritis, sarcoidosis, silicosis, and arteriovenous malformations.

Questions relating to smoking history, drug abuse, and alcohol abuse are standard in MedicalTemplates. These questions have increased importance in the evaluation of patients with lung masses. Patients who smoke are at 10-20 times more likely to develop lung cancer, and many other cancers (i.e., gastric, pancreatic, cervical, larynx, esophagus and colon cancer) are also related to smoking.

E & M Documentation Template

The lung mass evaluation MedicalTemplate contains prompters and space for all the required elements for a new or subsequent outpatient E&M encounter.  

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



• 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 lung mass 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.

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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.