The Sleep Disorder evaluation MedicalTemplate is suitable for any physician or health care provider that evaluates patients with sleep disorders such as sleep apnea, narcolepsy, or restless leg syndrome. Licenses for MedicalTemplates start at $99 for a single user.  Volume discounts are available. When completed, and in conjunction with a supporting level of medical decision making, the Sleep Disorder 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

Sleep Disorder Evaluation Template

Impact of Sleep Disorders on the Healthcare system

Sleep disorders include obstructive sleep apnea, narcolepsy, restless leg syndrome, insomnia, night terrors and others.  The National Center on Sleep Disorders Research (NCSDR) estimates that 42 million Americans suffer from a chronic sleep disorder.   Sleep disorders are associated with chronic sleep deprivation, elevated blood pressure, cardiovascular disease, pulmonary hypertension, cognitive dysfunction, erectile dysfunction, chronic fatigue, and other medical conditions that result in $15.9 billion in health care costs annually.  Sleep disorders can have a  detrimental influence in the workplace and school performance, and people who are chronically sleep deprived due to sleep disorders are at increased risk of auto accidents.

The Sleep Disorder Evaluation MedicalTemplate has prompters for the sleep history, medical history, medication use that affects sleep architecture, drug use history, auto accident history, physical examination, and testing options.  This assists physicians in efficiently documenting a thorough history.  

E & M Documentation Template

The sleep disorder 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 sleep disorder 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.

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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.