March 11, 2008

New Problem Specific MedicalTemplate Bundle

The new MedicalTemplate bundles have been expanded to include the Problem Specific Bundle. The Problem Specific Bundle includes 6 MedicalTemplates at a 25% discount.

MedicalTemplates in the Problem Specific Bundle -


Save 25% and Buy pulmonary disease bundle now from REGNOW.COM

New Hypertension Management MedicalTemplate

A new hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected hypertension (high blood pressure) was released today.

The Hypertension management MedicalTemplate includes reminders for the JNC7 hypertension management goals.




Read this document on Scribd: Hypertension Follow up Evaluation

Hypertension Evaluation Date Start Time Stop time Patient Name Patient DOB MRN Chief complaint/Reason for consult History of Present Illness Referring MD Data Reviewed ‰Allergy list ‰Medication list ‰Past Medical History ‰Past Surgical History ‰Social History ‰Family Medical History ‰Patient’s Blood Pressure log ‰Recent labs and diagnostic tests Review of Systems ‰Premature Coronary Artery Disease ‰Hyperlipidemia ‰Cardiac disease ‰Congenital Adrenal Hyperplasia ‰Diabetes ‰Dyslipidemia ‰Renal disease ‰Polycystic Ovarian Syndrome ‰Sleep Apnea ‰Renal artery stenosis Pulse Sitting RR Standing ‰Thyroid disease ‰BMI t  ‰Smoking ‰Physical inactivity Physical Exam Vitals Ht Wt BMI BP L arm R arm General ‰ Alert Eyes ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro Psych Supine ‰ = Patient denies problems ‰Constitutional ‰Eyes ‰Vision changes ‰Pain ‰Weight changes ‰Fatigue ‰Fever ‰ENT/mouth ‰Resp ‰CV ‰GI ‰Ulcers ‰Tooth pain ‰Nose bleeds ‰Dyspnea ‰Cough ‰Sputum ‰Chest pain ‰Exercise intolerance ‰Diaphoresis ‰Paroxysmal nocturnal dyspnea ‰Nausea ‰Vomiting ‰Diarrhea ‰ Abdominal pain after eating ‰Dysuria ‰Polyuria ‰Erectile dysfunction ‰Myalgias ‰Bony pain ‰Claudication ‰Sores, ulcers ‰Dry, cracked skin ‰Numbness ‰Paresthesias ‰Focal weakness ‰Hypoglycemia ‰Tremors ‰GU Additional Findings ‰Conjunctivae ‰Pupils ‰Discs ‰No visible retinal pathology ‰Nasal mucosa ‰Dentition ‰Oropharynx ‰Normal to palpation ‰Thyroid ‰No JVD ‰Clear to auscultation ‰Clear to percussion ‰Effort ‰Normal to palpation ‰Auscultation ‰Palpation ‰Edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength ‰No clubbing ‰No cyanosis ‰No sores ‰Inspection ‰Palpation ‰Oriented ‰CN ‰DTR ‰Sensation intact ‰Vibratory sense intact ‰Affect ‰Orientation ‰Insight ‰Memory ‰Musc ‰Skin/breasts ‰Neuro ‰Endo Impression & Plan Blood Pressure Class ‰Normal ‰Prehypertension ‰Stage 1 ‰Stage 2 SBP <120 120-139 140-159 t160 DBP <80 80-89 90-99 t100 ‰Patient at goal < 140/90 or <130/80 for DM ‰Not at Goal ‰Heme/lymph ‰Allergy/Immun ‰Psych ‰Easy bruising ‰Swollen lymph nodes ‰Sinus pain ‰Nasal discharge ‰Depression ‰Anxiety ‰Hallucinations Follow up ‰This clinic ‰Endocrinology ‰Nephrology ‰Ophthalmology ‰Other Signature cc Estimated Creatinine Clearance * Multiply by 0.85 for females Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2 (140 – age) x weight (in kg) = Plasma Creatinine x 72 Labs Therapy ‰Urinalysis ‰CBC ‰PT, PTT, INR ‰BMP ‰LFTs ‰Triglyceride level ‰LDL and HDL ‰BNP ‰EKG ‰ECHO ‰TSH ‰Aspirin ‰ACE-I or ARB ‰Beta blocker ‰Calcium Channel Blocker ‰Thiazide diuretic ‰Loop diuretic ‰Statin ‰Other ©MB and RR 2006-2008 Revised 10March08 e-medtools.com



JNC 7 Guidelines

The hypertension evaluation MedicalTemplate includes the hypertension staging system and reminders for the suggested laboratory workup outlined in the JNC 7 report. The JNC 7 is the The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure of the National Heart, Lung, and Blood institute.

JNC 7 Full Guidelines
JNC 7 Pocket Reference

March 10, 2008

Save 15-25% on MedicalTemplate Bundles

MedicalTemplate Bundles allow customers to save 15-25% when purchasing multiple MedicalTemplates.

MedicalTemplate Bundles Available
Primary Care (4 MedicalTemplates)
Chronic Disease Management (4 MedicalTemplates)
Pulmonary (5 MedicalTemplates)
Pulmonary Disease (6 MedicalTemplates)

March 7, 2008

New Sepsis Evaluation MedicalTemplate

The sepsis evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected sepsis, SIRS, or septic shock.

The sepsis evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity, including critical care.




Read this document on Scribd: Sepsis Evaluation MedicalTemplate

Sepsis Evaluation Date Start time Stop time Patient Name Chief complaint/Reason for consult Patient DOB Referring MD MRN Allergies ‰ Allergy List reviewed ‰ No drug allergies ‰ No food allergies Medications History of Present Illness ‰Patient is Nonverbal. History obtained from ‰ Family ‰ Medical records ‰Medication list reviewed ‰Medications reconciled with Nursing Home or Hospital discharge Information œ46 ‰Heart rate t 90 ‰Temp d36 C or t 38 C ‰Resp rate t 20 OR PCO2 d 32 on ABG ‰WBC d4000 ORt 12000 OR t 10% Bands ‰Positive blood culture = Sepsis PLUS = Systemic Inflammatory Response Syndrome PLUS ‰SBP < 90; MAP d 70 mmHg OR drop of t 40 mmHg = Severe Sepsis PLUS ‰Systolic BP d 90,or MAP d 70 = Septic Shock Social History ‰Never Smoker ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ WNL ‰Alcohol use Drinks per ‰day ‰week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day 1 “drink” is equal to 12 oz. beer,1.5 oz. 80-proof liquor, or 5 oz. glass of wine Constitutional ‰Fatigue ‰malaise ‰fever/chills ‰Appetite changes Eyes ‰Vision changes ‰New pain ‰Scotomas ENT/mouth ‰Nose bleeds ‰Dental caries ‰Dental abscesses ‰Jaw pain Resp ‰Dyspnea ‰Cough ‰Phlegm ‰Hemoptysis ‰Wheeze CV ‰Chest pain ‰Diaphoresis ‰Ankle edema ‰PND ‰Syncope GI ‰Nausea ‰Weight changes ‰Constipation ‰Diarrhea ‰Abdominal pain GU ‰Change in urinary habits ‰Hematuria ‰Dysuria Musc ‰Myalgias ‰Recent trauma ‰Bony fractures ‰Arthralgias ‰Joint swelling Skin/breasts ‰Rashes ‰Masses or skin lesions ‰Increased sensitivity to sun Neuro ‰Seizures ‰Episodic or chronic muscle weakness ‰Headaches Endo ‰Hair loss ‰Polydipsia ‰Tremors ‰Neck pain Heme/lymph ‰Bleeding gums ‰Unusual bruising ‰Lymph nodes, tender or swollen Allergy/Immun ‰Sinus probs ‰Recurrent infections Psych ‰Mood changes ‰Agitation ‰Psychosis ‰Delirium ‰Dementia ‰Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics ‰Benzodiazepines Family Medical History ‰ Asthma ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰Premature Onset ‰ Malignancy ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Renal Dysfunction ‰ Thrombotic disorder ‰ Thyroid Disease Occupational and Exposure History ‰Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter ‰Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals ‰Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic ‰Chemicals or fires ‰Trauma Vaccines ‰Flu ‰Pneumo ‰BCG ‰Tetanus ‰Pertussis ‰Varicella ‰CABG ‰Splenectomy ‰Pituitary resection ‰Organ transplant ‰Other Surgeries Past Medical and Surgical History ‰Asthma ‰Adrenal dysfunction ‰Arthritis ‰Cerebral Artery Disease ‰CHF ‰COPD ‰Coronary Artery Disease ‰Cystic Fibrosis ‰Diabetes ‰1 ‰2 ‰GERD ‰Gout ‰Hepatic dysfunction ‰HIV/AIDS ©MB and RR 2006-2008 ‰Hypertension ‰Inflammatory Bowel Disease ‰Malignancy ‰Myocardial Infarction ‰Neuromuscular weakness ‰Pancreatitis ‰Peripheral Artery Disease ‰Renal dysfunction ‰Thrombotic disease ‰Thyroid disease, hyper ‰Thyroid disease, hypo ‰Seizure disorder ‰Sleep Apnea ‰Chemotherapy ‰Colonoscopy ‰ECHO/Stress test ‰Immunosuppressive therapy ‰Mammogram ‰Organ failure ‰PFTs ‰Pap Smear ‰Prior intubations ‰Radiation exposure ‰Sleep study ‰Steroid use, chronic ‰Strokes Revised7Aug08 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Sepsis Evaluation IV Medications & Labs Patient Name Exam Ventilator Mode Rate Patient DOB MRN ‰ Pressors ‰ Diuretics ‰ Heparin ‰ Thrombolytic ‰ Insulin ‰ Sedation ‰ Steroids ‰ Antibiotics ‰ TPN ‰ Narcotics ‰ Antiarrhythmics ‰ Crystalloids \____/ / \ ____ / ____ / ____ / \ \ \ ‰AC ‰SIMV + Pressure Support ‰Pressure Control ‰Pressure Support ‰Airway Pressure Release PEEP PS FiO2 PO2/FiO2 Plateau Pressure Tidal Vol NonInvasive Ventilator (CPAP, BiPAP) Settings General Eyes ENT Neck Resp ‰Clear to auscultation ‰ Clear to percussion CV ‰Auscultation ‰ Palpation ‰ Edema ‰Carotids ‰Alert Vitals T P ‰Conjunctivae ‰Pupils ‰Discs ‰Nasal mucosa ‰Dentition ‰Oropharynx ‰Normal to palpation ‰Thyroid ‰No JVD R BP Sats % Mallampati ‰I ‰II ‰III ‰IV GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux ‰No abdominal/flank ecchymoses Lymph ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength Extrem ‰No clubbing ‰No cyanosis Skin ‰Inspection ‰Palpation ‰Effort ‰Normal to palpation ‰ Aorta ‰Femoral pulses ‰ Pedal pulses Neuro ‰Oriented œ58(Pts with Community Acquired Bacterial Pneumonia) Psych ‰Affect ‰Orientation ‰Insight ‰Memory Additional Findings ‰CN ‰DTR ‰Sensation Glasgow Coma Score E ____ V ____ M ____ Recommendations Impression APACHE II Score ____ APACHE IV Score _____ ‰Aggressive pulmonary toilet ‰DVT prophylaxis ‰Stress ulcer prophylaxis ‰Stop sedation daily assess neuro status ‰Head of bed >30 Degrees at all times ‰Insulin infusion ‰Pneumonia vaccine prior to discharge ‰Influenza vaccine prior to discharge ‰Central line placement ‰Central line change/removal Culture tip ‰Physical therapy ‰Enteral/Parenteral feeds ‰CVP monitor placement ‰Central or Mixed Venous O2 ‰12-lead EKG ‰Echocardiogram ‰CBC ‰CMP ‰PT, PTT, INR ‰Lactate ‰Random cortisol level ‰Toxicology Screen ‰Blood Alcohol level ‰Blood cultures x 2 ‰Broad spectrum antibiotics ‰Pseudomonas suspected Goal t 70% Goal CVP 8-12 ‰Shock requiring ‰Large volumes of Fluid ‰Pressors ‰Likely source of infection or ischemia present, describe ‰Acute renal failure ‰with chronic failure ‰with ESRD ‰Acute hepatic failure ‰with chronic failure ‰Acute heart failure ‰Right ‰Left ‰with chronic failure ‰Acute respiratory distress syndrome ‰Acute respiratory failure ‰with chronic failure ‰Disseminated Intravascular Coagulation ‰Adrenal Crisis OR ‰Relative Adrenal Insufficiency ‰Multiple Organ Dysfunction Syndrome Signature cc ‰ Patient has completed advanced health care directivesœ47 HCPOA is Code Status ‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION Data Reviewed: Care Coordinated with: ‰ER Notes ‰Chart ‰Nursing Notes/Vitals log ‰Labs ‰Radiology data ‰ECHO ‰ECG ‰Stress Test ‰PFT ‰HCPOA ‰ PCP ‰Case Mgmt or SW ‰Pharmacy ‰Nursing Revised7Aug08 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures ©MB and RR 2006-2008

New Diabetes chronic disease management MedicalTemplate

The new diabetes evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected diabetes.

This MedicalTemplate is designed for chronic disease management.

The diabetes evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity.




Read this document on Scribd: Diabetes Evaluation

Diabetes Evaluation Date Start Time Stop time Patient Name Patient DOB MRN Chief complaint/Reason for consult History of Present Illness Referring MD Data Reviewed ‰Allergy list ‰Med list ‰Past Medical History ‰Past Surgical History ‰Social History ‰Family Medical History ‰Patient’s Blood Glucose log ‰Recent labs Review of Systems Physical Exam General Eyes ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro Psych ‰ = Patient denies problems ‰Constitutional ✔ ‰Eyes ‰Weight changes ‰Fatigue ‰Fever ‰Vision changes ‰Pain ‰Ulcers ‰Tooth pain ‰Sore throat ‰Dyspnea ‰Cough ‰Sputum ‰Chest pain ‰Exercise intolerance ‰Nausea ‰Vomiting ‰Diarrhea ‰ENT/mouth ‰Resp ‰CV ‰GI ‰GU ‰Musc ‰Dysuria ‰Polyuria ‰Discharge ‰Myalgias ‰Bony pain ‰ Alert Ht Wt BMI Pulse RR BP ‰Conjunctivae ‰Pupils ‰Discs ‰No visible retinal pathology ‰Nasal mucosa ‰Dentition ‰Oropharynx ‰Normal to palpation ‰Thyroid ‰No JVD ‰Clear to auscultation ‰Clear to percussion ‰Effort ‰Normal to palpation ‰Auscultation ‰Palpation ‰Edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength ‰No clubbing ‰No cyanosis ‰No sores ‰No corns ‰No ingrown nails ‰Normal wear pattern on shoes ‰Inspection ‰Palpation ‰Oriented ‰CN ‰DTR ‰Sensation intact ‰Vibratory sense intact ‰Affect ‰Orientation ‰Insight ‰Memory Additional Findings ‰Skin/breasts ‰Neuro ‰Endo Impression & Plan ‰Sores, ulcers ‰Dry, cracked skin ‰Numbness ‰Paresthesias ‰Hypoglycemia ‰Tremors ‰Heme/lymph ‰Allergy/Immun ‰Psych ‰Easy bruising ‰Swollen lymph nodes ‰Sinus pain ‰Nasal discharge ‰Depression ‰Anxiety ‰Hallucinations Follow up ‰This clinic ‰Podiatry Last exam ‰Ophthalmology Last exam ‰Other Signature cc ‰A1C ‰Urinalysis ‰CBC ‰BMP ‰LFTs ‰Triglyceride level ‰LDL and HDL ‰BNP ‰Cardiac enzymes ‰Troponin ‰TSH Auto-antibodies ‰Islet cell ‰insulin ‰GAD65 ‰ IA-2 ‰ IA-2E Therapy ‰Aspirin ‰ACE-I or ARB ‰Diuretic ‰Statin ‰Insulin ‰Metformin ‰Thiazolidinedione ‰Secretagogue ‰Other Labs ©MB and RR 2006-2008 Revised 4March08

New Gastroenterology MedicalTemplate

The new gastroenterology evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected gastroenterology disorders such as abdominal pain, GI bleeding, liver disease, and pancreatitis. The gastroenterology evaluation MedicalTemplate is tailored to meet the needs of gastroenterologists, but is suitable for all health care professionals.

The gastroenterology evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity.

New Psychiatry MedicalTemplate published

MedicalTemplates now includes a general psychiatry evaluation medical note template that can be downloaded from here.

The general psychiatry evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected psychiatric disorders such as depression and bipolar disorder. This MedicalTemplate includes all the required elements for the high complexity E&M documentation, tailored for the needs of mental health professionals.

March 5, 2008

OpenMedSpel on Mozdev

OpenMedSpel, our free and open source medical spelling word list, is now available on Mozdev.org.

openmedspel.mozdev.org


About Mozdev.org
Mozdev.org is a software development community dedicated to making quality applications and extensions freely available to all computer users. The goal of Mozdev.org is to help establish Mozilla as a viable application development platform.

About Mozilla
The mission of the Mozilla project is to preserve choice and innovation on the Internet. The Mozilla project is the producer and provider of the award-winning Firefox web browser and Thunderbird e-mail software.