Pleural Effusion Evaluation Medical Note Template
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The pleural effusion evaluation MedicalTemplate is suitable for any health care provider that evaluates patients with pleural effusions.
When completed, and in conjunction with a supporting level of medical decision making, the pleural effusion disease 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. |
Pleural Effusion Evaluation |
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 disease 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 pleural effusion disease 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.
