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

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