January 21, 2010

Clinic H&P Updates

The Clinic H&P MedicalTemplate for outpatient evaluations has undergone major updates and is now available!

The new, updated Clinic H&P now has helpful hints for assisting with documentation necessary for proper billing and coding, based on the 1997 Guidelines for Evaluation and Management Services. The Review of Systems has been updated to reflect "yes" and "no" options. The History of Present Illness has been expanded to permit more writing space. The Past History has been streamlined. The exam has been expanded to include pertinent positive and negative findings. The Impression and Plan section contains additional writing space, and has space for documenting code status and diagnostic plans.

We are confident that these updates will make patient encounter documentation easier and more likely to result in better coordination of documentation and coding!

Clinic History and Physical MedicalTemplate

January 14, 2010

New Inpatient Evaluation Template

The New Inpatient Evaluation template designed for the initial evaluation of hospital patients is now updated.

The most important change to the New Inpatient Evaluation template is that it has been modified to reflect the format and wording described in CMS' 1997 Guidelines for Evaluation & Management Services. Help buttons in major sections describe information regarding the documentation necessary for coding.

Other important upgraded features include:
1. Expanded Review of Systems with more signs and symptoms AND yes/no options
2. Streamlined Past Medical History
3. Expanded Exam with check boxes for pertinent positive and negative findings
4. Code status
5. 3 page format with expanded Impression and Plan

Like all MedicalTemplates, the New Inpatient Evaluation template is in Adobe Acrobat PDF format that contains active check boxes and fillable text boxes. The PDF format makes medical documentation with MedicalTemplates simple, efficient, and reliable. The PDF format makes it easy to carry information to any location, save data for later reference, and make changes as needed.

New Inpatient Evaluation (History and Physical)

January 8, 2010

COPD Evaluation Template for Outpatients

MedicalTemplates has released a new COPD (Chronic Obstructive Pulmonary Disease) Evaluation Template designed for use by all health care providers in the outpatient setting. The template is in a fillable PDF format by Adobe Acrobat and contains checkboxes and fillable textboxes.

The new COPD Evaluation Template has generous space for documenting the HPI, and contains prompters that readily distinguish the severity of illness and recent symptoms or events that may indicate a need for changes in the COPD medication regimen, or even hospitalization.

The Review of Systems has convenient buttons for checking "yes" or "no" options, dramatically reducing the time spent on this task.

The Past Medical, Family and Social History (PFSH) contains disease-specific prompters for common or relevant disorders. In addition, there are prompters for a detailed Malignancy history, occupational or inhalational exposure history, and common diseases among family members that may affect a patient's health.

The Exam emphasizes pertinent positive and negative exam findings, and contains space for free text documentation of additional findings.

The Impression and Plan is generously sized to permit detailed discussions, and contains convenient prompters for common treatments, diagnostics and lab tests.

Prompters with simple check boxes limit the need for handwriting or typing. Fillable text boxes permit free text descriptions for areas that require further, detailed documentation. Features such as these help to improve health care provider efficiency by decreasing the time needed to document a patient encounter, ensure that essential topics are discussed, improve documentation, and provide supporting documentation for adequate billing and coding needs. The COPD Evaluation Template was created following the Centers for Medicare & Medicaid Services' (CMS) 1997 E & M Documentation Guidelines, and the development team included a board-certified Pulmonary Disease Specialist.

The COPD Evaluation Template for outpatients is a valuable tool for all health care providers who evaluate and treat patients with COPD, or those at risk of developing COPD. The COPD Evaluation Template helps to make documentation as fast and easy as possible.

Outpatient evaluation for COPD Medical Documentation Template

January 4, 2010

e-MedTools Is Now On Twitter

Tweeting is our latest venture. Check out updates on e-MedTools, MedSpel and MedicalTemplates on our Twitter page.

We look forward to hearing from you!

Psychiatry Evaluation Template Updated!

Good Monday Morning!

MedicalTemplates has just released an updated version of the Psychiatry Evaluation Template. This version is far superior to the previous version!

The new Psychiatry Evaluation Template has increased the size of the HPI box for free text. The Review of Systems (ROS) has been expanded to include Yes/No options. The Past Psychiatric History (in the PFSH) has been expanded to include hospitalizations and treatments. The Exam portion is more detailed and contains expanded free text boxes, and the Impression section has been expanded to include prompters for Data Reviewed, Care Coordinated With, Recommended Diagnostics and Recommended Actions.

We think folks are going to love the improvements, and we value any and all feedback!

Thank you to all those who have already purchased a Psychiatry Evaluation Template! Look in your e-mail for your complementary updated MedicalTemplate!

Be sure to check us out on Twitter for more frequent updates:)

January 3, 2010

Trailblazer Medicare Audit Tool

The Trailblazer Medicare Audit Tool is designed for use by health care providers and their staff. Health care providers, even those in training, can use the Trailblazer Medicare Audit Tool to determine appropriate billing levels for the complexity of medical documentation for each patient encounter. It can also be helpful for learning the complexities of medical documentation, and for assisting internal audits for EM documentation. The Trailblazer Medicare Audit Tool is created in a fillable PDF format, permitting users to rapidly complete the form digitally on any computer, but can still be printed out and manually completed.

Each Trailblazer Medicare Audit Tool has readily visible and easy to use check boxes and fillable text boxes for marking the appropriate level of documentation for the medical History, Exam and Medical Decision Making.

The Trailblazer Medicare Audit Tool is subdivided into the following categories:
Medical Decision Making

The History is subdivided into the following categories:
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical, Family and Social History (PFSH)

Medical Decision Making is further subdivided into 3 categories:
Number of Diagnoses OR Number of Treatment Options
Data Reviewed or Ordered
Risk of Complications, Morbidity or Mortality

The sum of the 3 categories of Medical Decision Making determine the Complexity of Medical Decision Making.

The levels of the History, Exam and Complexity of Medical Decision Making determine the Overall Patient Encounter Level.

Trailblazer Medicare Audit Tool