The COPD evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, pulmonologists, and other health care providers that evaluate patients with known or suspected COPD in ambulatory or hospital settings.
This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with COPD.
This MedicalTemplate contains detailed checklists for the severity of COPD symptoms, current and planned COPD therapy, and other features helpful for a comprehensive COPD treatment plan.
The COPD evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new patient evaluation, consult, or follow up note.
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.
* History Click here to learn about History Documentation o Chief complaint o History of present illness o Past medical and surgical history o Social history + Risk factors for disease (occupational exposures, smoking, and others) o Family history o Review of systems + Yes/No checkboxes for clear and complete documentation * Examination Click here to learn about Physical Exam Documentation o When completed, represents a comprehensive (highest) level physical exam as defined in 1997 Guidelines.
o General Multisystem Exam o Checkboxes for pertinent negatives and common positive findings * Medical Decision Making Click here to learn about MDM Documentation o Full page for adequate space with complex patients o Easy Documentation with checkboxes + Review of labs, tests, imaging, old records + Coordination of care + Common diagnostic and therapeutic options o Assessment and plan.