COPD New Outpatient Evaluation Medical Note Template
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This COPD (Chronic Obstructive Pulmonary Disease) Evaluation Template
designed for use by all health care providers in the outpatient
setting. The template is in a fillable PDF format by Adobe Acrobat and
contains checkboxes and fillable textboxes.
The Review of Systems has convenient buttons for checking "yes" or "no"
options, dramatically reducing the time spent on this task. |
Outpatient evaluation for COPD Medical Documentation Template |
Impact of COPD on the Healthcare system
The National Center for Health Statistics reports COPD to be the 4th leading cause of death in the Unites States, causing 124,000 deaths per year. Over 24 million Americans have COPD, and women are more likely than men to die from COPD. The major risk factor for developing and dying from COPD is tobacco smoking. COPD is responsible for over 1 million hospital admissions and $37 billion dollars in healthcare costs each year. Due to the large numbers of Americans with COPD and the heath care costs associated with the treatment of COPD, this chronic lung disease is a focus of many quality improvement initiatives and pay for performance programs.
E & M Documentation Template
The COPD Outpatient 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
- Increasing severity & signs of exacerbation of COPD
-
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.
- 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 COPD Outpatient follow up 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.
