November 10, 2008

Medical Decision Making Calculator - Google Desktop

e-MedTools released a free Medical decision making calculator for Google Desktop.

Medical decision making (MDM) is a required component for all Evaluation and Management services (E&M), which include most clinic and hospital patient encounters.

This calculator is an excellent learning tool for clinicians that want to improve the accuracy of billing for E&M services,
and is based on the MDM assessment method used by most Medicare carriers nationwide.

Health care providers working in Delaware, Maryland, Texas, Virginia, or the District of Columbia should use the method developed by TrailblazerHealth (the Medicare carrier in the states mentioned above) to evaluate the Medical Decision Making portion of the E&M service, which is not included in the current version of this calculator.

November 2, 2008

Pulmonary Hospital H&P or Consult Note Updated

Our Pulmonary/Critical Care Hospital H&P or Consult note has been revised to give expanded space to document an assessment and plan, history, and has improved documentation reminders.

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, including critical care.

The pulmonary/critical care new patient evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a H&P or Consult.

History Click here to learn about History Documentation

    • Chief complaint
    • History of present illness
    • Past medical and surgical history
    • Social history
      • Risk factors for respiratory disease (occupational exposure, 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, represents a comprehensive (highest) level physical exam as defined in 1997 Guidelines.

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
Follow this link for a concise review of the medical documentation requirements for E&M services.

Pulmonary / Critical Care New Patient Evaluation

Pulmonary Evaluation Date Time Yes Constitution Fatigue Malaise Fever or chills Appetite changes Eyes Vision changes New pain Scotomas ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Urinary changes Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rashes Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Sinus problems Recurrent infections Psychologic Mood changes Agitation Hallucinations Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ Chief complaint/Reason for consult No Reset Referring MD History of Present Illness Patient is Nonverbal. History obtained from Family Medical records Elements of HPI: Location, quality, severity, timing, duration, context, modifying factors, associated signs and symptoms Reset Reset Reset Medications Medications reviewed Medications reconciled with Nursing Home or Hospital discharge Information Allergies Allergy List reviewed 46 No food or drug allergies Past Medical, Family Social History Reset Asthma Cerebral Artery Disease Bronchiectasis Congestive Heart Failure COPD Coronary Artery Disease COP (BOOP) Diabetes Cystic Fibrosis GERD Histiocytosis Hepatic Dysfunction Tuberculosis HIV/AIDS PAH Hypertension Sarcoidosis Inflam bowel disease Wegener’s Malignancy Obstructive Sleep Apnea CPAP BiPAP Malignancy Adrenal Colon Melanoma Renal cell Reset Reset Thyroid Neuromuscular weakness Occupational exposures Osteoporosis Pancreatitis Peripheral Artery Disease Scleroderma Seizure Disorder Sjogren’s Renal dysfunction/ failure Rheumatoid Arthritis Thrombotic Disease Thyroid disease Breast Lung Chemotherapy Colonoscopy ECHO/Stress Test Mammogram PFTs PapSmear Prior Intubations Radiation exposure Sleep Study Steroid use Prostate Testicular Surgeries Reset Social History / Risk factors Denies Denies Denies Yes Ever smoker ___ # Packs X ____ # Yrs Yes Chews tobacco Yes Quit tobacco use Quit date _________ Patient is unwilling to quit Patient willing to consider quitting Patient quit, but resumed smoking Patient willing to quit within 1 month Yes Yes Yes Yes Feels safe at home or work Tattoos High risk sexual behavior Recreational drug use Inhalational Injectable Denies Reset Yes Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade Reset Denies Denies Denies Denies Denies Ingestible Reset Denies Denies Denies Denies Denies Yes Yes Yes Yes Yes Alcohol use ___ Drinks per day week Felt the need to cut down on drinking? Annoyed by others criticizing drinking? Guilt associated with drinking? Eye opener needed? Yes Drug dependence Narcotics Benzodiazepines Occupational and Exposure History Reset Reset 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 Hot tub or Jacuzzi or High Pressure washings Pets or feathers Chemicals or fires Family Medical History Reset Asthma CHF COPD Coronary Artery Dis Thrombotic disorder Thyroid Disease Malignancy in first degree relatives, specify Pancreatitis Peripheral Artery Disease Renal Dysfunction ©MB and RR 2006-2008 Revised 31Oct08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Pulmonary Evaluation Exam Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ General Multisystem requires performing ALL of ≥9 organ systems, AND ≥2 elements documented in each organ system Height ___________ in cm To qualify as a comprehensive exam: Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND ≥1 element in every other organ system is expected lb kg Regular Irregular Ventilator, IV Medications & Labs Ventilator Mode PRVC Rate AC SIMV PC Constitutional (≥ 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam Weight ___________ Pulse Rate __________ Temperature __________ AND Rhythm Other ____________ __________ Blood Pressure lying Respiratory Rate__________ Body habitus wnl Cachectic Unkempt Obese Blood Pressure sitting __________ / __________ OR standing __________ / __________ __________ / __________ Optional Sats _____ % Cardiac Output _____ SVR _____ Tidal Vol __________ PEEP PS FiO2 __________ __________ __________ ENT Grooming wnl Nasal mucosa, septum, and turbinates wnl PO2/FiO2__________ Plateau __________ NonInvasive Ventilator CPAP BiPAP Dentition and gums wnl Oropharynx wnl Dental caries Gingivitis Oral ulcers Oral Petechiae Mallampati Oropharyngeal edema or erythema I II III IV Neck Neck wnl Thyroid wnl Dose Rate Erythema or scarring consistent with Thyromegaly Recent Old radiation dermatitis Neck mass ___________________________ Thyroid nodules palpable IV Medications Pressors Jugular Veins wnl JVD present a, v or cannon a waves present ____________________________ ____________________________ Antihypertensives Resp Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis Scarring consistent with old, healed radiation dermatitis Respiratory effort is wnl Accessory respiratory muscle use Intercostal retractions ____________________________ Diuretics ____________________________ Antibiotics Chest percussion wnl Tactile exam wnl Dullness to percussion Tactile fremitus Increased Clear to auscultation Bronchial breath sounds Rub present ________________________ Paradoxic diaphragmatic movements Lt Rt Hyperresonance Lt Rt ____________________________ ____________________________ Sedation Decreased _____________________________________ Egophony (E to A) Rales Rhonchi Wheezes ____________________________ Narcotics CV Clear S1 S2 Murmur present No murmur, rub or gallop Systolic Gallop I Rub II III IV V VI Weak Pulsatile Diastolic Grade No peripheral edema LUQ RUQ Liver Axilla Groin ____________________________ Heparin Peripheral pulses palpable Peripheral pulses LLQ Absent ____________________________ Insulin GI ____________________________ Antiarrhythmics Lymph node exam wnl Areas examined Lymphadenopathy noted in Neck Axilla Abdominal exam wnl Mass present RLQ ____________________ Liver Spleen ____________________________ Steroids Liver and spleen palpation wnl Unable to palpate Lymph (≥2 areas must be examined) Neck Spleen Enlarged Groin Other ___________________ ____________________________ Paralytic Other ___________________ Musc Muscle tone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present ____________________________ Thrombolytic ____________________________ TPN Gait and station wnl Labs \____/ / \ ____ / ____ / ____ / \ \ \ Extrem Skin No rashes, ecchymoses, nodules, ulcers Exam wnl Clubbing Cyanosis Ataxia Wide based gait Shuffle Patient leaning Petechiae Synovitis Rt Rt Lt Front Back Lt ________________________ Splinter hemorrhages Person Depressed Time Place Periungual telangiectasias Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) NOT oriented to Anxious Affect is within normal limits OR Patient appears Glasgow Coma Score E _____ V _____ M _____ Agitated APACHE II Score __________ ©MB and RR 2006-2008 Revised 31Oct08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Pulmonary Evaluation Data Reviewed ER Notes Old medical records Labs Radiology data ECHO ECG Stress Test Pulmonary Function Test Nursing Notes/Vitals log Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ Impression Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION Patient has completed advanced health care directives 47 HCPOA is _______________________________________ Care Coordinated with Patient HCPOA / Surrogate PCP Consultant Case Management or Social Worker Pharmacy Nursing Physical Therapist Occupational Therapist Speech Therapist Recommended Actions Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis Daily sedation vacation and neurologic assessment Head of bed elevated > 30 Degrees at all times Intense glycemic control Insulin infusion Central line change or removal (send tip for culture) Physical therapy Enteral/Parenteral feeds Smoking cessation aids Pneumonia vaccine prior to discharge Influenza vaccine prior to discharge Recommended Diagnostics PPD Testing 12-lead EKG Echocardiogram Sputum culture Bacterial Blood culture Urine culture CSF culture CBC with differential PT, PTT, INR BMP (with calcium) HIV Hepatitis panel Fungal AFB Signature ________________________________________ cc __________________________________ ©MB and RR 2006-2008 Revised 31Oct08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Pulmonary and Critical Care New Patient Evaluation Template Definitions Sepsis Positive blood culture AND Heart rate >⁄= 90 Temp <⁄= 36 C or >⁄= 38 C Resp rate >⁄= 20 OR PCO2 <⁄= 32 on ABG WBC <⁄=4000 OR >⁄= 12000 OR >⁄= 10% Bands Without a positive blood culture, the above findings are consistent with Systemic Inflammatory Response Syndrome (SIRS) www.e-medtools.comStart time Date Stop time Physiologic Score Temp ______ HR MAP RR Oxygenation >181 <40>49 <6>105.7 93.2-96.7 Heart Rate 70-109 n/a 110-139 140-179 >161 55-69 40-54 <>70 130-139 61-70 150-154 155-159 120-129 2.5-2.9 200-349 130-159 35-49 Serum Na Serum K Severe Sepsis The patient must meet the above criteria AND have hypotension, hypoperfusion or organ dysfunction. Hypotension is defined as SBP <>/= 40 mmHg Oxygenation If FiO2 > 49%, A-a If FiO2 <>500 <54>179 <>7.1 <>3.4 >7.69 <7.15>39 <1.0>59 <20 score =" 15" score =" Acute" 45 ="0" 54 =" 2" 64 =" 3" 74 =" 5">74 =6 Age Score ______ Predicted Mortality Based on APACHE II Score Score 5-9 10-14 15-19 20-24 25-29 30-34 over 34 Interpretation ~4% death rate ~8% death rate ~15% death rate ~25% death rate ~40% death rate ~55% death rate ~75% death rate ~85% death rate Ventilator Strategies ( 4 5 15-29 <15>/= 30 degrees Stages of chronic kidney disease 2. Daily sedation vacation AND Stage GFR (mL/min/1.73m2 ) Action assessment of ability to wean from 1 >89 Diagnosis and treatment. Treat comorbid conditions. Slow progression. ventilator 2 60-89 Estimate progression 3. Stress ulcer prophylaxis 3 38-59 Evaluate and treat complications 4. Deep Venous Thrombosis prophylaxis Oxygen Coverage PO2<⁄=55 OR Sats <⁄=90% PO2 56-59 OR Sats 89% WITH CHF Cor pulmonale P wave >2mm lead II, III or AVF Hct >56% Sats <⁄=88% for >5 minutes during sleep NOT COVERED PO2 >59 OR Sats >89% The National Kidney Foundation recommends estimating GFR by use of the Cockcroft-Gault or MDRD equations General Acid-Base Rules Acidosis Acute Resp ∆pH = -0.008 x ∆PCO2 ∆HCO3 = 0.1 x ∆PCO2 (+/-3) Chronic Resp PCO2 = 2.4(HCO3) – 22 ∆HCO3 = 0.35 x ∆PCO2 (+/-4) Metabolic PCO2 = 1.5(HCO3) + 8 +/-2 PCO2 ~ last 2 digits pH ∆PCO2 = 1.2 x ∆HCO3 Alkalosis ∆pH = 0.008 x ∆PCO2 ∆HCO3 = -0.2 x ∆PCO2 (usually not to less than 18 mEq/L) ∆HCO3 = -0.4 x ∆PCO2 (usually not to less than 18 mEq/L) PCO2 = 0.9(HCO3) + 9 +/-2 ∆PCO2 = 0.6 x ∆HCO3 ©MB and RR 2006, 2007 Revised 13Nov07 Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures