December 15, 2008

COPD Evaluation Medical Template Revised

Our COPD Evaluation MedicalTemplate (Consult note or H&P) has been revised to give expanded space to document a review of systems, 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 COPD 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
    • COPD symptoms and severity checklist
    • Past medical and surgical history
    • Social history
      • Risk factors for COPD and other respiratory diseases (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.
    • 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

Chronic Obstructive Pulmonary Disease Evaluation COPD Evaluation Patient Name Review of Systems Yes Constitution Fatigue Malaise Fever or chills Appetite changes 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 No Reset DOB Chief complaint/Reason for consult Date Start time Referring Healthcare Provider Stop time History of Present Illness COPD Symptom Asymptomatic with usual activity Patient is Nonverbal. History obtained from FEV1/FVC >/=70% <70%>80% >79% SEVERITY Family Medical records Chronic Bronchitis symptoms Increased cough Increased dyspnea or wheeze Increased sputum production Change in sputum color/quality Reset At risk Mild Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest Reset 50-79% Moderate 30-49% Severe <30%> lb lying / Obese kg Temp standing Grooming appropriate P rate / Reg R Irreg Sats % BP sitting General ENT Neck Cachectic Unkempt appearance Nasal mucosa Dental caries Dentition Gingivitis Oropharynx Mallampati I II III IV Oral Petechiae Oropharyngeal edema or erythema No JVD JVD present Oral ulcers Thyromegaly Thyroid nodules palpable Erythema consistent with radiation dermatitis Normal to palpation Thyroid Neck mass ______________________________ Scarring consistent with old, healed radiation dermatitis No respiratory distress No chest wall defects Resp Clear to auscultation Decreased fremitus Dullness to percussion Bronchial breath sounds Rales Egophony (E to A change) Rhonchi Wheezes Accessory respiratory muscle use Erythema consistent with radiation dermatitis Scarring consistent with old, healed radiation dermatitis Peripheral pulses palpable III IV V No peripheral edema Absent Weak CV GI Clear S1 S2 Murmur No murmur Systolic No gallop No rub I II No palpable masses Hepatomegaly Diastolic Grade VI Peripheral pulses Splenomegaly Liver and spleen not palpable No hepatojugular reflux Diagnostic Data \____/ / \ ____ / ____ / ____ / \ \ \ Lymph Musc Extrem Skin Neuro No lymphadenopathy Lymphadenopathy Increased Neck Axilla Groin Other ______________________ Muscle tone within normal limits Gait within normal limits No clubbing Clubbing Decreased Shuffle Synovitis Rt Lt _______________________ Ataxia Wide based Cyanosis No cyanosis No rashes, ecchymoses, nodules, ulcers Oriented to person, time, place, situation Affect Periungual telangiectasias 58(Pts with CABP) Splinter hemorrhages Person Time Place NOT ORIENTED to ©MB and RR 2006-2008 Revised13Oct08 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 COPD Evaluation Patient Name Plan Impression 52 DOB Date Start time Stop time COPD Therapy PRN albuterol “rescue agent” Inhaled corticosteroids Oral steroids Intravenous steroids Long-acting beta agonist Theophylline Long-acting anti-cholinergic Antibiotics for exacerbations Smoking cessation aids Long term oxygen therapy Patient advised to quit smoking Patient advised of risks of alcohol, narcotic and benzodiazepine use Medication Side Effects discussed 52 If no history of glaucoma or urinary retention Patient has completed advanced health care directives 47 HCPOA is Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION Mental status changes OR 2 of the following Dyspnea at rest Respiratory rate > 25 Severe COPD exacerbation requiring hospitalization as evidenced by Pulse > 100 Accessory respiratory muscle use 52 Schedule Patient For Bronchoscopy Pulmonary Function Testing Methacholine Challenge 6 Minute Walk Test Bone density evaluation CXR Chest CT 12 lead ECG ECHO with bubble study assess PA pressures Cardiopulmonary Stress Test Sleep Study CT Surgery eval for lung reduction Pulmonary Rehabilitation Pneumococcal vaccine Influenza vaccine with contrast Signature cc Continuous home oxygen therapy Flow rate _______L/min Oxygen concentrator Oxygen tank with conservation valve Nasal cannula with reservoir Portable oxygen tank Gas Liquid Supplemental oxygen therapy during air travel Flow rate _______L/min Home CPAP Flow rate _______ L/min Heater and humidifier Mask type Nasal Oronasal Face Home BiPAP Inspiratory flow _______/Expiratory flow _______ Heater and humidifier Mask type Nasal Oronasal Face ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Case Management Labs X Rays MRI Pharmacy US CT Labs CBC BMP CMP BNP LFTs Alpha 1 antitrypsin Cultures Blood Sputum Other Data Reviewed Care Coordinated With ER MD HCPOA Primary Care MD Social Worker ©MB and RR 2006-2008 Revised13Oct08 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

December 8, 2008

OpenMedSpel for 3.0

OpenMedSpel has been updated for 3.0 and higher, and is listed on Extensions!.

includes nearly 50,000 medical terms ranging from abdominis to zygomatic, which allows you to concentrate on your work instead of looking up words in a medical dictionary that are not in the built-in USA English spelling dictionary.

OpenMedSpel is free and open source medical spelling software released under a GPL license.

Download OpenMedSpel for Extentions - OpenMedSpel