Orthopedic Medical Note Template
|
The orthopedic evaluation
MedicalTemplate is
suitable for
orthopedic surgeons, internal medicine
physicians, family practice
physicians, and other
health care providers that evaluate patients
with bone or joint
problems. Licenses for 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, the orthopedic 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. |
Orthopedic Evaluation MedicalTemplate |
E & M Documentation Template
The orthopedic evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new patient evaluation or outpatient 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.
- Musculoskeletal examination
- 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 orthopedic 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.
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.
