Pneumonia Evaluation Medical Note Template
- E&M Documentation Template
- Digital Health Record
- Digital Signature Option
- Reminders
- Follow Up
- Referral
- Labs
- Therapeutic options
- Medicare PQRI
| Template updated
2/9/08 | Template Features
|
Pneumonia and the health care system
Statistics from the U.S. Department of Health and Human Services show pneumonia to be the eighth leading cause of death in the United States, causing about 90,000 deaths per year. Each year pneumonia affects 4 million Americans, is responsible for 1 million hospital admissions, and results in 10 billion dollars in health care costs. The overall mortality rate of pneumonia is 13 percent, and is influenced by factors such as age, living in a nursing home, or having cardiac or renal disease. The large numbers of people affected by pneumonia and the associated health care costs make pneumonia care a focus for many health care quality improvement initiatives.
Features of the Pneumonia medical documentation template
The
Pneumonia Evaluation MedicalTemplate
contains prompters
for ascertaining different symptoms associated with pneumonia, such as
dyspnea,
chest pain, pleuritic pain, cough, fever, chills, nightsweats, and
hemoptysis. Other
prompters help identify patients who
are at higher risk of aspiration pneumonia, multi-drug resistant
infections, or
infections due to less common causes including fungus, legionella,
SARS, avian
influenza, tuberculosis, and other microbes.
Questions to document smoking history, drug abuse (both
prescription and
street drugs), and alcohol abuse are included to identify patients who
are at
increased risk of certain types of pneumonia.
Differentiating pneumonia from other
medical conditions that
produce a similar appearance on a chest x-ray challenging. The Pneumonia Evaluation MedicalTemplate
includes
prompters to help identify patients who may have other medical
conditions such
as myocardial infarction, heart failure, vasculitis, inhalation injury,
or
esophageal rupture that can cause produce a pneumonia like appearance
on chest
x-ray.
Pneumonia Severity Index
This MedicalTemplate includes the pneumonia severity index (PSI) which was developed by an Agency for Healthcare Research and Quality-funded multidisciplinary research team called the Pneumonia Patient Outcomes Research Team (PORT). This reliable and well tested decision support tool can assist physicians in determining if a pneumonia patient should be treated at home or in a hospital.
E & M Documentation Template
The pneumonia 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
The pneumonia 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 pneumonia 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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