March 7, 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

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