The pneumonia evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers that evaluate patients with known or suspected pneumonia in ambulatory or hospital settings.  This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with pneumonia.     When completed, and in conjunction with a supporting level of medical decision making, the pneumonia 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. How to use MedicalTemplates

Pneumonia Evaluation

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.

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 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 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 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.