Saturday, August 18, 2012

E/M Template




Evaluation and Management (E/M) Template

PT TYPE: OFFICE/NEW_____ OFFICE/EST _______

Hosp Obs____ Hosp Obs w/ Adm & DC ______ ER ________ CONSULT OFC/OP _________Consult Initial IP______

Consult FU IP______ Consult Confirm_______

Nursing facility Initial Comprehensive Assessment_____

Nursing facility Subsequent______

CC_____________

HISTORY

HISTORY OF PRESENT ILLNESS:

____Location diffuse/localized, unilateral/bilateral, fixed/migratory

____Duration How long? 20 min, onset 3 yrs ago, since last Friday, for approx 2 months, since yesterday

____Quality sharp, dull, burning, gnawing, fullness, aching, throbbing, stabbing, radiating, color of sputum, non-productive, asymptomatic etc. Laceration jagged/straight. Sore throat scratchy

____Context What was going on at time symptoms occurred, exercise, big meals, dairy products, spicy foods, etc. What were they doing when it occurred, MVA, running down steps, sitting in chair, playing sports.

____Severity Rank of pain on pain scale 0-10, severe, slightly, worst I’ve ever had, mild, moderate, 0 pain, increase, decrease, progressive, well, major, poor, significant, complicated (must be ranked; can’t just say “pain in my leg”

____Modifying Factors What makes better or worse, any meds helping, rest or eating, affected by spicy foods, ice pack or quiet room for MHA, coughing irritates the pain, OTC or prescribed meds have been attempted, etc What were the results?

____Timing Onset, night, day, continuous, occasional, episodic, AM, PM, constant, recurrent, seldom, frequently, off and on, morning, evening, intermittent, transient.

____Signs/Symps Associated with…, Negative Responses will count

Document of at least 3 chronic/inactive conditions_____

REVIEW OF SYSTEMS:

Negative, Normal, WNL can count in any/all systems
_____Constitutional – Activity, appearance, appetite, exercise, fatigue, fevers, mood, sweats, weakness, wt change, chills

_____Eyes - Blurred vision, drainage, dryness, flashing, pain, photophobia, redness, tearing, vision change

_____ENT & Mouth - Airway, balance, bleeding, discharge, hearing, pain, ringing, smell, swallowing, taste, voice

_____CV - Chest pain, diaphoresis, dizziness, exertional pain, irregular beats, leg cramps, orthopnea, palpitations, peripheral edema, radiation, SOB

_____Respiratory - Allergies, cough, dyspnea, hemoptysis, pain, SOB, sputum, wheezing

_____GI - Appetite, Change in bowel habits, constipation, diarrhea, heartburn, hemetemesis, indigestion, nausea, pain, rectal bleed, swallowing, thirst, vomiting

_____GU – Burning, discharge, dribbling, frequency, hematuria, incontinence, menopause, nocturia, odor, pain, pregnancies, starting, stopping, urgency, dyuria

_____All/Imm – Allergies to meds, chemo, hay fever, HIV/AIDS, hives, immune suppression, immunizations, sweating

_____MS - Limitation of activity, pain, redness, stiffness, swelling, weakness

_____Skin – bleeding, color change, cyanosis, dryness, growths, jaundice, rash

_____Neuro – blackout, HA, memory loss, numbness, seizure, syncope, tingling, tremors

_____Psych – Anxiety, delusion, depression, hallucination, insomnia, nervous, panic, personality, phobia, suicidal

_____Endocr – Change hair pattern, heat/cold intolerance, polydiipsia, Polyphagia, polyuria, sweating

_____Hem/Lym – bleeding, bruising, gland swelling, menses, nodes

_____Documentation of adequate ROS & all others negative


PFSH :

_____Past Medical History

Surgeries

Any item labeled as PMH may only be used for that. This is true for even chronic 
problems. Don’t try to count them for HPI or ROS elements

Diagnostic tests, even when they appear in the HPI area, can only be used as PMH.

Don’t try to count them as something else

_____Family History

Family History of Neoplasms

Family History of Congenital / Hereditary conditions

_____Social History

Smoking, Alcohol, Marital status

____Unable to do comprehensive history due to patient condition


PHYSICAL EXAM

CONSTITUTIONAL (2) 

____BP, Pulse, Respiration, Temp, Ht, Wt Measurement of any 3 of the above VS. (May be measured/recorded by staff person)

____GENERAL APPEARANCE – Development, Nutrition, Body habitus, Deformities, Grooming

EYES (3)

____ Conjunctivae, Lids

____ Pupils and Irises PERRLA

____ SCOPE EXAM, Optic discs, C/D ratio (Cup to Disk Ratio), Size,Appearance
Posterior segments,Vessel changes, Exudates, hemorrhages

EARS, NOSE, MOUTH, THROAT (6)

____External auditory canals, TM’s

____EARS & NOSE – Appearance, Scars, Lesions, Masses

____Hearing, Whispered voice, Finger rub, Tuning Fork

____NOSE - Mucosa, Septum, Turbinates

____MOUTH – Lips, Teeth, Gums

____THROAT/OROPHARYNX – Oral mucosa, Salivary glands, Hard and soft palates, Tongue, Tonsils, Posterior pharynx

NECK (2) 

____NECK – Masses, Appearance, Symmetry, Tracheal position, Crepitus

____THYROID – Enlargement, Tenderness, Mass

RESPIRATORY (4) 

____Effort, Retractions, Muscles, Movement

____Percussion, Dullness, Flatness, Hyper resonance

____Palpation, Fremitus

____Auscultation, Breath sounds, Rubs

CARDIOVASCULAR (7) 

____Palpation, Location, Size, Thrills

____Auscultation, Abnormal sounds, Murmurs

          ARTERIES –
____Carotid, Pulse, Bruits

____Abdominal Aorta,Size, Bruits

____Femoral, Pulse, Bruits

____Pedal Pulse

____Extremities, Edema, Varicosities

CHEST/BREASTS (2)

____Breasts, Symmetry, Nipple discharge

____Breasts and axillae, Mass, Lump, Tenderness

GI/ABDOMEN (5) 

____Abdomen, Mass, Tenderness

____Liver, Spleen

____Hernia

____Anus, Perineum, Rectum, Sphincter tone, Hemorrhoids, Rectal mass

____Occult blood


GU, FEMALE (6)

____External genitalia, Appearance, Hair distribution, Lesions,

____Vagina, Appearance, Estrogen effect, Discharge, Lesions, Pelvic support, Cystocele, Rectocele

____Urethra, Mass, Tenderness, Scarring

____Bladder, Fullness, Mass, Tenderness

____Cervix, Appearance, Lesions, Discharge

____Uterus, Contour, Position, Mobility, Tenderness, Consistency, Descent or Support

____Adnexa/Parametria, Mass, Tenderness, Organomegaly, Nodules

GU, MALE (3)

____Scrotum, Hydrocele, Spermatocele, Tenderness of cord, Testicular mass

____Penis, phallus 

____DRE of prostate for Size, Symmetry, Nodules, Tenderness 

LYMPHATIC (4) 

 ____Nodes

 ____Neck

 ____Axillae 

____Groin

____Other

MS (26) 

____Gait, Station, Romberg, Ambulatory?? 

____Nails/Digits, Clubbing, Cyanosis, Inflammation, Petechiae, Ischemia, Infection, Nodes

HEAD AND NECK

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion, EOMI

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

SPINE, RIBS, AND PELVIS

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements 

EXTREMITIES, RUE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

EXTREMITIES, LUE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

RLE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

LLE

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion

____ROM, Pain, Crepitation, Contracture

____Stability, Dislocation, Subluxation, Laxity

____Muscle strength, Tone, Atrophy, Abnormal movements

SKIN (2) 

____Inspection, Rash, Lesion, Ulcer

____Palpation, Induration, Nodule, Tightening

NEURO (3) 

____Cranial deficits

____DTR, Babinski

____Sensation, Touch, Pin, Vibration, Proprioception

PSYCH (4) 

____Judgement, Insight

____AO x 3

____Memory, recent and remote

____Mood and affect, Depression, Anxiety, Agitation


MEDICAL DECISION MAKING:


DX: TYPE OF PROBLEM:

_____Self-limited or minor

_____Established same/improving ____ Established, worsening

_____New, no additional workup ____New, with additional workup

_____Are any of the above illnesses a severe exacerbation, progression or side effect of treatment?

MANAGEMENT OPTIONS:

_____OTC Meds ____Phys/Occ Therapy

_____Prescrip/IM meds ____Closed Fx/dislocation w/o

_____IV meds manipulation

_____IV meds w/ additives ____Minor surg w/o risk factors

_____High Risk meds ____Minor surg w/ risk factors

_____Telemetry ____Major surg w/o risk factors

_____Respiratory treatments ____Major surg w/ risk factors

_____Nuclear Medicine ____Major emergency surger

____Decision not to resuscitate

----------------------------

_____Decision to obtain old medical records and/or obtain Hx from someone other than patient

_____Review and summ of old records and/or obtain Hx from someone other than patient

_____Discussion of case with another health care provider

Time spent in minutes w/ patient or family_____________


LABS:

_____CBC/UA ____Cardiac enzymes

_____Flu/Strep/Monospot ____ABG

_____PG test _____PT/PTT

_____Amylase _____T&C

_____BUN/Creat _____Superficial Bx

_____Electrolytes _____Deep/incisional Bx

_____ETOH/Drug screen ____Other labs 0-9

_____Chem profile 

----------------------

_____Independent visualization of test

_____Discussion w/ performing physician

X-RAY/RADIOLOGY:

_____Chest ____GI/Gallbladder series

_____Extremities ____IVP

_____Abdomen ____CAT scan

_____Hip/Pelvis ____MRI

_____C-spine ____Vascular studies w/o risk

_____Diagnostic US ____Vascular studies w/ risk

_____Discography ____Other X-ray 0-9

_____T/L spine

-----------------------

_____Independent visualization of test

_____Discussion w/ performing physician

OTHER DIAGNOSTIC TESTS:

_____EKG ____Nuclear scan

_____Holter ____Lumbar puncture

_____Treadmill/stress ____Thoracentesis

_____EEG/EMG ____Culdocentesis

_____Vectorcardiogram ____Endoscope w/o risk

_____Doppler flow ____Endoscope w/ risk

_____Pulmonary

------------------------------

_____Independent visualization of test

_____Discussion w/ performing physician

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