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Last Modified 5/13/2008
Pleural Effusion Evaluation Medical Note Template
The pleural effusion evaluation MedicalTemplate is suitable for any health care provider that evaluates patients with pleural effusions.
- E&M Documentation Template
- Digital Health Record
- Digital Signature Option
- Reminders
- Follow Up
- Referral
- Labs
- Therapeutic options
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Move pointer over template for larger image Template updated on 2/9/08 |
Template Features
 Shopper Support |
What is a pleural effusion?
A
pleural effusion is a collection of
excess fluid in the pleural space which is between the lungs and the
chest wall. Chest pain and difficulty breathing are the most common
symptoms.
Pleural effusions are concerning because they can
indicate the presence of malignancies, such as lung cancer, lymphoma,
metastatic cancer, or rarely, mesothelioma. Fortunately, the most
common causes of pleural effusions are a wide range of treatable
medical conditions such as congestive heart failure (CHF), pneumonia,
pancreatitis, lupus, kidney disease, liver disease, tuberculosis,
and others. Because so many medical conditions can be associated with
pleural effusions, it can be difficult to positively determine the
etiology.
Determining the cause of the pleural effusion
requires a detailed medical and occupational history that includes
outside interests, such as hobbies, and a complete physical exam. All
new pleural effusions of substantial volume must be evaluated by a
thoracentesis. This is done by inserting a needle or tube into the
pleural fluid, and sending the fluid for laboratory analysis.
Laboratory analysis includes evaluation of the presence of bacteria,
inflammatory cells, cancer cells, proteins indicative of tuberculosis,
esophageal rupture or urinothorax, or antibodies indicative of
autoimmune disease.
The pleural effusion evaluation medical
template provides historical and laboratory prompters for the
physician, facilitating a thorough and efficient investigation. Much of
the documentation is done by clicking on checkboxes. Text boxes are
provided to facilitate individualized documentation of the history,
physical exam and impression and plan.
E & M Documentation Template
The pleural effusion evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.
- History
- Chief complaint
- History of present illness
- Past medical and surgical history
- Social history
- Family history
- Review of systems
- Examination
- Medical Decision Making
- Review of data (labs, tests, imaging, old records)
- Assessment and plan
- 1997
Documentation Guidelines for Evaluation and Management
Services
- 1995
Documentation Guidelines for Evaluation and Management
Services
Digital Health Record
Filled pleural effusion evaluation 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.
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The pleural effusion evaluation medical note template can be customized to meet your needs.
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.
