|
SURGICAL HISTORY
|
|
|
SURGICAL HISTORY
|
DICTATION
|
|
PAST SURGICAL HISTORY
• • •
|
SURGICAL HISTORY COMMENT
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
CONSTITUTIONAL WNL
|
DICTATION
|
|
Fever
|
CHILLS
|
|
NIGHT SWEATS
|
WEAKNESS
|
|
FATIGUE
|
LOSS OF APPETITE
|
|
UNEXPLAINED WEIGHT LOSS
|
EXPLAINED WEIGHT LOSS
|
|
UNEXPLAINED WEIGHT GAIN
|
|
|
|
|
|
SKIN: WNL
|
DICTATION
|
|
Dry Skin
|
Rashes
|
|
Itching
|
Suspicious Moles or Lesions
|
|
|
|
|
HEME / LYMPHATIC: WNL
|
DICTATION
|
|
Excessive Bruising
|
Bleeding
|
|
Lymphadenopathy
|
Anemia
|
|
Current Anticoagulant Use
|
|
|
|
|
|
HEAD/FACE
|
DICTATION
|
|
Headaches
|
Facial Injury
|
|
Head Injury
|
|
|
|
|
|
EYES WNL
|
DICTATION
|
|
Blurred Vision
|
Double Vision
|
|
Eye Pain/Irritation
|
Wears Glasses/Contacts
|
|
History of Cataracts
|
History Glaucoma
|
|
Photophobia
|
|
|
|
|
|
ENT: WNL
|
DICTATION
|
|
Earache
|
Tinnitis
|
|
Vertigo
|
Decreased Hearing
|
|
Dysphagia
|
Sinus Congestion/Drainage
|
|
Prolonged Hoarseness
|
Frequent Sore Throat
|
|
Bleeding Gums
|
Epistaxis
|
|
Dentures
|
Hearing Aids
|
|
|
|
|
SLEEP APNEA: WNL
|
DICTATION
|
|
Daytime Somnolence
|
Snoring
|
|
Fatigue
|
Lack of Energy
|
|
|
|
|
CARDIAC/PERIPHERAL VASCULAR: WNL
|
DICTATION
|
|
Exertional Chest Pain
|
Non-exertional chest pain
|
|
Palpitations (fast heart beat)
|
Irregular Heart Beat
|
|
Shortness of Breath- Exertion
|
Shortness of Breath- Without Exertion
|
|
Varicose Veins
|
Blood Clots in Legs
|
|
Swollen Ankles
|
|
|
|
|
|
GASTROINTESTINAL: WNL
|
DICTATION
|
|
Nausea
|
Vomiting
|
|
Diarrhea
|
Constipation
|
|
Change in Bowel Habit
|
Abdominal Pain
|
|
Bloody Stool
|
Jaundice
|
|
Hearburn
|
Incontinence
|
|
Bloating
|
|
|
|
|
|
GU: WNL
|
DICTATION
|
|
Dysuria
|
Hematuria
|
|
Urinary Frequency
|
Incontinence
|
|
Nocturia
|
Hesitant Urination
|
|
|
|
|
GYN: WNL
|
DICTATION
|
|
Vaginal Discharge
|
Menorrhagia/Metrorhagia
|
|
Breast Mass or Tenderness
|
Desires Hormone Replacement?
|
|
|
|
|
MALE SEXUALITY: WNL
|
DICTATION
|
|
Erectile Dysfunction
|
Decreased Libido
|
|
|
|
|
ENDOCRINE: WNL
|
DICTATION
|
|
Cold / Heat Intolerance
|
Polyphagia
|
|
Polyuria
|
Polydypsia
|
|
Unexplaied Weight Gain
|
Weight Loss
|
|
|
|
|
MUSCULOSKELETAL: WNL
|
DICTATION
|
|
Muscle Cramping
|
Muscle Weakness
|
|
Edema
|
Muscle Stiffness
|
|
Claudication
|
Joint Swelling
|
|
Arthritis
|
|
|
|
|
|
RHEUMATOLOGICAL:WNL
|
DICTATION
|
|
Neck Pain
|
Shoulder Pain
|
|
Elbow Pain
|
Wrist Pain
|
|
Hand Pain
|
Mid-Back Pain
|
|
Low Back Pain
|
Leg Pain
|
|
Hip Pain
|
Knee Pain
|
|
Ankle Pain
|
Foot Pain
|
|
|
|
|
NEUROLOGIC: WNL
|
DICTATION
|
|
Headache
|
Limb Weakness
|
|
Limb Pain
|
Limb Numbness/Tingling
|
|
Tremor
|
Seizures/Convulsions
|
|
Fainting
|
Stroke/TIA
|
|
Dizziness/Vertigo
|
|
|
|
|
|
PSYCHOLOGICAL: WNL
|
DICTATION
|
|
Anxiety
|
Depression
|
|
Mania
|
Tearfulness
|
|
|
|
|
FAMILY HISTORY
|
|
|
FAMILY HISTORY
|
DICTATION
|
|
Father's MH
• • •
|
FATHER MH COMMENT
|
|
Mother's MH
• • •
|
MOTHER MH COMMENT
|
|
Sibling(s)' MH
• • •
|
SIBLING(S) MH COMMENT
|
|
Children(s)' MH
• • •
|
CHILDREN MH COMMENT
|
|
|
|
|
SOCIAL HISTORY
|
|
|
SOCIAL HISTORY
|
DICTATION
|
|
Marital Status
• • •
|
Marital Status Comments:
|
|
Children
|
Children Comments:
|
|
Living Arrangements
• • •
|
Living Arrangement Comments:
|
|
Alcohol Use
• • •
|
Alcohol use comments:
|
|
Illicit Drug Use
• • •
|
Illicit Drug Use Comments:
|
|
Tobacco
• • •
|
Tobacco Use Comments:
|
|
ASSISTED LIVING ARRANGEMENTS
|
Tobacco Use Comments:
|
|
DNR
|
|
|
|
|
|
GENERAL PHYSICAL EXAM
|
|
|
PE CONSTITUTIONAL: WNL
|
DICTATION
|
|
Constitutional Abnormal
• • •
|
Constitutional Comments
|
|
|
|
|
PE BODY STATISTICS
|
DICTATION
|
|
HEIGHT
|
WEIGHT
|
|
BODY TYPE
|
|
|
|
|
|
VITAL SIGNS
|
DICTATION
|
|
BLOOD PRESSURE
/
|
HEART RATE (# only)
|
|
RESPIRATORY RATE (rpm)
|
|
|
|
|
|
PE HEENT WNL
|
DICTATION
|
|
HEENT Abnormal
• • •
|
HEENT Comments
|
|
PE NECK WNL
|
DICTATION
|
|
Neck Abnormal
• • •
|
Neck Comments
|
|
PE CHEST WALL WNL
|
DICTATION
|
|
Chest Wall Abnormal
• • •
|
Chest Wall Comments
|
|
PE HEART WNL
|
DICTATION
|
|
Cardiovascular Abnormal
• • •
|
Heart Comments
|
|
PE LUNGS WNL
|
DICTATION
|
|
Lungs Abnormal
• • •
|
Lungs Comments
|
|
PE ABDOMEN WNL
|
DICTATION
|
|
Abdomen Abnormal
• • •
|
Abdomen Comments
|
|
PE SKIN WNL
|
DICTATION
|
|
Skin Abnormal
• • •
|
Skin Comments
|
|
PE EXTREMITIES WNL
|
DICTATION
|
|
Extremities Abnormal
• • •
|
Extremities Comments
|
|
|
|
|
MUSCULOSKELETAL EXAM
|
|
|
PE MSK GAIT WNL
|
DICTATION
|
|
MSK- GAIT Abnormal
• • •
|
MSK GAIT Comments
|
|
PE MSK STATION WNL
|
DICTATION
|
|
MSK- Station Abnormal
• • •
|
MSK Station Comments
|
|
PE MSK CERVICAL WNL
|
DICTATION
|
|
MSK- Cervical Abnormal
• • •
|
MSK Cervical Comments
|
|
PE MSK RT SHOULDER WNL
|
DICTATION
|
|
MSK- Right Shoulder Abnormal
• • •
|
MSK Right Shoulder Comments
|
|
PE MSK LT SHOULDER WNL
|
DICTATION
|
|
MSK- Left Shoulder Abnormal
• • •
|
MSK Left Shoulder Comments
|
|
PE MSK RT ELBOW WNL
|
DICTATION
|
|
MSK- Right Elbow Abnormal
• • •
|
MSK Right ElbowComments
|
|
PE MSK LT ELBOW WNL
|
DICTATION
|
|
MSK- Left Elbow Abnormal
• • •
|
MSK Left Elbow Comments
|
|
PE MSK RT WRIST/HAND WNL
|
DICTATION
|
|
MSK- Right Wrist/Hand Abnormal
• • •
|
MSK Right Wrist/Hand Comments
|
|
PE MSK LT WRIST/HAND WNL
|
DICTATION
|
|
MSK- Left Wrist/Hand Abnormal
• • •
|
MSK Left Wrist/Hand Comments
|
|
PE MSK THORACIC SPINE WNL
|
DICTATION
|
|
MSK- Thoracic Spine Abnormal
• • •
|
MSK Thoracic Spine Comments
|
|
PE MSK LUMBAR SPINE WNL
|
DICTATION
|
|
MSK Lumbar Spine Abnormal
• • •
|
MSK Lumbar Spine Comments
|
|
PE MSK SACRAL SPINE WNL
|
DICTATION
|
|
MSK Sacral Spine Abnormal
• • •
|
MSK Sacral Spine Comments
|
|
MSK RIGHT HIP WNL
|
DICTATION
|
|
MSK Right Hip Abnormal
• • •
|
MSK Right Hip Comments
|
|
MSK LEFT HIP WNL
|
DICTATION
|
|
MSK Left Hip Abnormal
• • •
|
MSK Left Hip Comments
|
|
MSK RIGHT THIGH WNL
|
DICTATION
|
|
MSK Right Thigh Abnormal
• • •
|
MSK Right Thigh Comments
|
|
MSK LEFT THIGH WNL
|
DICTATION
|
|
MSK Left Thigh Abnormal
• • •
|
MSK Left Thigh Comments
|
|
MSK RIGHT KNEE WNL
|
DICTATION
|
|
MSK Left Thigh Abnormal
• • •
|
MSK Right Knee Comments
|
|
MSK LEFT KNEE WNL
|
DICTATION
|
|
MSK Left Knee Abnormal
• • •
|
MSK Left Knee Comments
|
|
MSK RIGHT LOWER LEG WNL
|
DICTATION
|
|
MSK Right Lower Leg Abnormal
• • •
|
MSK Right Lower Leg Comments
|
|
MSK LEFT LOWER LEG WNL
|
DICTATION
|
|
MSK Left Lower Leg Abnormal
• • •
|
MSK Left Lower Leg Comments
|
|
MSK RIGHT ANKLE WNL
|
DICTATION
|
|
MSK Right Ankle Abnormal
• • •
|
MSK Right Ankle Comments
|
|
MSK LEFT ANKLE WNL
|
DICTATION
|
|
MSK Left Ankle Abnormal
• • •
|
MSK Left Ankle Comments
|
|
MSK RIGHT FOOT WNL
|
DICTATION
|
|
MSK Right Foot Abnormal
• • •
|
MSK Right Foot Comments
|
|
MSK LEFT FOOT WNL
|
DICTATION
|
|
MSK Left Foot Abnormal
• • •
|
MSK Left Foot Comments
|
|
|
|
|
PSYCHIATRIC EXAMINATION
|
|
|
PSYCHIATRIC EXAM
|
DICTATION
|
|
PSYCHIATRIC NORMAL STATEMENT
|
DICTATION
|
|
CLIENT APPREARANCE
|
CLIENT APPEARANCE- OTHER
|
|
CLIENT PERSONAL HYGIENE
|
CLIENT PERSONAL HYGIENE - OTHER
|
|
CLIENT BEHAVIOR
• • •
|
CLIENT BEHAVIOR- OTHER
|
|
CLIENT MOOD
• • •
|
CLIENT MOOD - OTHER
|
|
CLIENT AFFECT
• • •
|
CLIENT AFFECT - OTHER
|
|
CLIENT THOUGHT PROCESSES
• • •
|
CLIENT THOUGHT PROCESSES OTHER
|
|
CLIENT CONTENT OF THOUGHT
• • •
|
CLIENT CONTENT OF THOUGHT OTHER
|
|
CLIENT JUDGEMENT & INSIGHT
• • •
|
CLIENT JUDGEMENT & INSIGHT OTHER
|
|
|
|
|
COGNITIVE EXAMINATION
|
|
|
COGNITIVE EXAMINATION
|
DICTATION
|
|
LEVEL OF CONSCIOUSNESS
|
|
|
ORIENTATION
• • •
|
|
|
MEMORY
• • •
|
|
|
|
|
|
LANGUAGE EXAM
|
|
|
LANGUAGE EXAM
|
DICTATION
|
|
SPEECH
• • •
|
Speech Comment
|
|
READING ABILITY
|
Reading Ability Comment
|
|
WRITING ABILITY
|
Writing Ability Comment
|
|
WRITTEN COMPREHENSION
|
Written Comprehension Comment
|
|
VERBAL COMPREHENSION
|
Verbal Comprehension Comment
|
|
NAMING
|
Naming Comment
|
|
REPEATS
|
Repeats Comment
|
|
|
|
|
FOLSTEIN MINI MENTAL STATUS EXAM SCORE 30/30
|
|
|
FOLSTEIN
|
DICTATION
|
|
Folstein Normal Results
|
DICTATION
|
|
ORIENTATION TO TIME
|
ORIENTATION TO PLACE
|
|
REGISTRATION
|
ATTENTION AND CALCULATION
|
|
RECALL
|
LANGUAGE
|
|
REPETITION
|
COMPLEX COMMANDS
|
|
FOLSTEIN MINI MENTAL STATUS EXAM TOTAL
|
|
|
|
|
|
CRANIAL NERVES
|
|
|
CRANIAL NERVE EXAMINATION
|
DICTATION
|
|
CRANIAL NERVES EXAM NORMAL
|
Crainial Nerves Normal Statement Dictation
|
|
CRANIAL NERVE I
|
|
|
CRANIAL NERVE II
• • •
|
|
|
CRANIAL NERVES III, IV,VI
• • •
|
|
|
CRANIAL NERVE VII
|
|
|
CRANIAL NERVE VIII
• • •
|
|
|
CRANIAL NERVE XI
• • •
|
|
|
Cranial Nerve XII
|
|
|
|
|
|
MOTOR EXAM
|
|
|
MOTOR EXAM
|
DICTATION
|
|
NORMAL STATEMENTS
|
NORMALS- DICTATION
|
|
Shoulder Elevation Over Head
|
SHOULDER ELEVATION OVER HEAD COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Shoulder Elevation
|
SHOULDER ELEVATION COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Prevents Scapular Winging
|
PREVENTS SCAPULAR WINGING COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Elevates and Retracts Scapula
|
ELEVATES AND RETRACTS SCAPULA COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Externally Rotates The Shoulder
|
EXTERNALLY ROTATES SHOULDER COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Abducts Arm First 30 Degrees
|
ABDUCTS ARM FIRST 30 DEGREES COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Abducts Arm >30<90
|
ABDUCTS ARM >30<90 COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Elbow Flexion In Mid-Position
|
ELBOW FLEXION IN MID-POSITION COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Elbow Flexion With Forearm Supinated
|
ELBOW FLEXION FOREARM SUPPINATED COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Elbow Extension
|
ELBOW EXTENSION COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Forearm Suppinator
|
FOREARM SUPPINATOR COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Pronates Forearm With Arm Extended
|
PRONATES FOREARM ARM EXTENDED COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Pronates Forearm With Elbow Flexed
|
PRONATES FOREARM ELBOW FLEXED COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Radial Wrist Extension
|
RADIAL WRIST EXTENSION COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Ulnar Wrist Extension
|
ULNAR WRIST EXTENSION COMMENT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Radial Wrist Flexion
|
RADIAL WRIST FLEXION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Ulna Wrist Flexion
|
ULNAR WRIST FLEXION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Index Finger Extension
|
INDEX FINGER EXTENSION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Flexion Of The Distal Tip Of Thumb #1 (0 Sign)
|
FLEXION DISTAL TIP OF THUMB
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
#2 And #3 Distal Tip Finger Flexion (0 Sign)
|
#2 and #3 DISTAL TIP FINGER FLEXION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Thumb Abduction
|
THUMB ABDUCTION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Index Finger Abduction
|
INDEX FINGER ABDUCTION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Little Finger Abduction
|
LITTLE FINGER ABDUCTION
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Adduct Index, Ring, Middle Toward The Middle
|
ADDUCT INDEX, RING TOWARD MIDDLE
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Thumb Touches (Opposition) Little Finger
|
THUMB TOUCHES LITTLE FINGER
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Flex The Fingers At The MC/P Joint
|
FLEX FINGERS AT MC/P JOINT
|
|
Right Upper Extremity
|
Left Upper Extremity
|
|
Hip Flexion/Abduction/External Rotation
|
HIP FLEXION/ABDUCTION/EXTERNAL ROTATION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Flexion Of The Thigh On The Hip
|
FLEXION OF THIGH ON HIP
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Extension and External Rotation Of The Thigh
|
EXTENSION/EXTERNAL ROTATION THIGH
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Abduction/Internal Rotation Thigh
|
ABDUCTION/INTERNAL ROTATION THIGH
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Adduction Of Thigh
|
ADDUCTION OF THIGH
|
|
Right Lower Extremity
|
Left Upper Extremity
|
|
Knee Extension
|
KNEE EXTENSION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Knee Flexion/Hip Extension
|
KNEE FLEXION/HIP EXTENSION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Ankle Dorsiflexion
|
ANKLE DORSIFLEXION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Ankle Plantar Flexion
|
ANKLE PLANTAR FLEXION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Ankle Eversion
|
ANKLE EVERSION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Ankle Inversion
|
ANKLE INVERSION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
Great Toe Extension
|
GREAT TOE EXTENSION
|
|
Right Lower Extremity
|
Left Lower Extremity
|
|
|
|
|
ASSOCIATED MOTOR EXAM
|
|
|
ASSOCIATED MOTOR MOVEMENT EXAM
|
DICTATION
|
|
ASSOCIATED MOTOR EXAM NORMAL STATEMENT
|
NORMAL STATEMENT DICTATION
|
|
BRADYKINESIA
|
ASSOCIATED MOTOR EXAM NORMAL STATEMENT
|
|
DYSKINESIA
|
|
|
CHOREA
|
|
|
BLEPHAROSPASM
|
|
|
OROMANDIBULAR DYSTONIA
|
|
|
PARKINSONISM
|
|
|
SPASMATIC TORTICOLLIS
|
|
|
TREMOR : CEREBELLAR 3-5
|
|
|
TREMOR: ESSENTIAL 4-9
|
|
|
TREMOR: ORTHOSTATIC: 13-18
|
|
|
TREMOR- PARKINSON'S RESTING 5
|
|
|
TREMOR- PHYSIOLOGICAL: 8-12
|
|
|
TRUNK DYSTONIA
|
|
|
GENERALIZED DYSTONIA
|
|
|
|
|
|
SENSORY EXAM
|
|
|
SENSORY EXAM
|
DICTATION
|
|
SENSORY EXAM NORMAL STATEMENT
|
NORMAL EXAM DICTATION
|
|
LIGHT TOUCH
|
LIGHT TOUCH COMMENT
|
|
POSITION SENSE
• • •
|
POSITION SENSE COMMENT
|
|
VIBRATORY SENSE
• • •
|
VIBRATORY SENSE COMMENT
|
|
RHOMBERG TEST
|
RHOMBERG TEST COMMENT
|
|
|
|
|
COORDINATION/CEREBELLAR EXAM
|
|
|
COORDINATION/CEREBELLAR EXAM
|
DICTATION
|
|
COORDINATION/CEREBELLAR EXAM NORMAL STATEMENT
|
NORMAL STATEMENT COMMENT
|
|
COORDINATION/CEREBELLAR EXAM RIGHT
• • •
|
COORDINATION/CEREBELLAR EXAM LEFT
• • •
|
|
|
|
|
REFLEX EXAMINATION
|
|
|
REFLEXES
|
DICTATION
|
|
REFLEXES NORMAL STATEMENT
|
NORMAL STATEMENT DICTATION
|
|
REFLEXES ABSENT
• • •
|
REFLEXES +1
• • •
|
|
REFLEXES +2
• • •
|
REFLEXES +3
• • •
|
|
REFLEXES +4
• • •
|
|
|
BICEPS- RIGHT
|
BICEPS- LEFT
|
|
BRACHIORADIALIS- RIGHT
|
BRACHIORADIALIS- LEFT
|
|
TRICEPS-RIGHT
|
TRICEPS- LEFT
|
|
KNEE JERK- RIGHT
|
KNEE JERK- LEFT
|
|
ANKLE JERK- RIGHT
|
ANKLE JERK- LEFT
|
|
|
|
|
SPECIAL TESTS
|
|
|
SPECIAL TESTS
|
|
|
CLONUS RIGHT
• • •
|
CLONUS LEFT
• • •
|
|
HOFFMAN'S SIGN RIGHT
|
HOFFMAN'S SIGN LEFT
|
|
BABINSKI RIGHT
• • •
|
BABINSKI LEFT
• • •
|
|
|
|
|
WADDELL’S SIGN (Non Physiological Exam)
|
|
|
WADDELL'S SIGN
|
DICTATION
|
|
WADDELL'S SIGN NORMAL STATEMENT
|
NORMAL STATEMENT DICTATION
|
|
GIVE-AWAY WEAKNESS
|
PAIN ON AXIAL LOADING
|
|
SUPERFICIAL TENDERNESS
|
PAIN ON PASSIVE ROTATION OF SHOULDERS & PELVIS
|
|
OVERREACTION TO ANY MOVEMENT
|
STRAIGHT LEG RAISE DISCREPANCY
|
|
PAIN ON STIMULATION
• • •
|
SITTING EXAM AND SUPINE EXAM
|
|
|
|
|
COORDINATION OF CARE
|
|
|
COORDINATION OF CARE
|
|
|
|
|
|
REFERRAL LETTERS REVIEWED
|
|
|
COC- REFERRAL LETTER REVIEWED
|
DICTATION
|
|
REFERRAL LETTER STATEMENT
|
|
|
PHYSICIAN REFERRAL LETTER
• • •
|
PHYSICIAN REFERRAL LETTER OTHER
|
|
REFERRAL LETTER PA, HEALTH CARE PROFESSIONAL, NURSE CASE MANAGER
|
REFERRAL LETTER PA, HEALTH CARE PROFESSIONAL, NURSE CASE MANAGER
|
|
REQUEST FOR LETTER FROM REFERRAL PHYSICIAN
|
|
|
|
|
|
DIAGNOSTIC STUDIES, LABS, NOTES, HOSPITAL RECORDS REVIEWED
|
|
|
DIAGNOSTIC STUDIES
|
DICTATION
|
|
Review Of Diagnostic Studies Other Physicians
|
REVIEW OF DIAGNOSTIC STUDIES COMMENT
|
|
Doctor Requested Results Of Diagnostic Laboratory Studies Ordered By Other Physicians
|
REQUEST RESULTS OF DIAGNOSTIC LABORATORY STUDIES OTHER PHYSICIANS COMMENT
|
|
Review Of Hospital Records
• • •
|
REVIEW OF HOSPITAL RECORDS COMMENT
|
|
REVIEW OF DIAGNOSTIC STUDIES FROM PREVIOUS APPT
|
REVIEW OF DIAGNOSTIC STUDIES FROM PREVIOUS APPT COMMENTS
|
|
|
|
|
NEURODIAGNOSTIC STUDIES REVIEWED
|
|
|
NEURODIAGNOSTIC STUDIES
|
DICTATION
|
|
NERVE CONDUCTION STUDIES/EMG
|
NERVE CONDUCTION STUDIES- EMG COMMENT
|
|
WAKING EEG
• • •
|
WAKING EEG COMMENT
|
|
SLEEP DEPRIVED EEG
• • •
|
SLEEP DEPRIVED EEG COMMENT
|
|
POLYSOMNOGRAM
• • •
|
POLYSOMNOGRAM COMMENT
|
|
MULTIPLE SLEEP LATENCIES
• • •
|
MULTIPLE SLEEP LATENCIES COMMENT
|
|
|
|
|
CARDIAC STUDIES
|
|
|
COC-CARDIAC STUDIES
|
DICTATION
|
|
TRANS TRORACIC CARDIAC ULTRASOUND
• • •
|
TRANS TRORACIC CARDIAC ULTRASOUND COMMENT
|
|
TRANS ESOPHAGEAL CARDIAC ULTRASOUND
• • •
|
TRANS ESOPHAGEAL CARDIAC ULTRASOUND COMMENT
|
|
BUBBLE ECHO
• • •
|
BUBBLE ECHO COMMENT
|
|
12 LEAD EKG (ELECTROCARDIOGRAM)
• • •
|
12 LEAD EKG COMMENT
|
|
24 HOUR HOLTER MONITOR
• • •
|
24 HOUR HOLTER MONITOR COMMENT
|
|
|
|
|
COORDINATION OF CARE PULMONARY DIAGNOSTIC TEST
|
|
|
PULMONARY DIAGNOSTIC TEST
|
DICTATION
|
|
PULMONARY FUNCTION TESTS NORMAL
|
PULMONARY DIAGNOSTIC TEST NORMAL STATEMENT
|
|
PULMONARY FUNCTION TEST
• • •
|
PULMONARY FUNCTION TEST COMMENT
|
|
ARTERIAL BLOOD GASES
• • •
|
ARTERIAL BLOOD GASES COMMENT
|
|
OVERNIGHT OXIMETRY READING
• • •
|
OVERNIGHT OXIMETRY READING COMMENT
|
|
|
|
|
LAB WORK
|
|
|
LAB WORK
|
|
|
COORDINATION OF CARE BLOOD WORK
|
DICTATION
|
|
BLOOD WORK
• • •
|
BLOOD WORK COMMENT
|
|
|
|
|
COC- ANTICONVULSANT BLOOD LEVELS
|
DICTATION
|
|
ANTICONVULSANT BLOOD LEVELS RESULTS
• • •
|
ANTICONVULSANT BLOOD LEVELS COMMENTS
|
|
|
|
|
COORDINATION OF CARE OPIATE SERUM DRUG LEVELS
|
DICTATION
|
|
OPIATE SERUM DRUG LEVELS
|
|
|
OPIATE SERUM DRUG LEVELS
• • •
|
OPIATE SERUM DRUG LEVELS COMMENTS
|
|
|
|
|
HORMONE/ENZYME ASSAYS
|
DICTATION
|
|
HORMONE/ENZYME ASSAYS
• • •
|
HORMONE/ENZYME ASSAYS COMMENT
|
|
|
|
|
CT/MRI/PET/RADIOLOGY/NUCLEAR MEDICINE
|
|
|
CT/MRI/PET/RADIOLOGY/NUCLEAR MEDICINE
|
DICTATION
|
|
|
|
|
PET SCAN
|
DICTATION
|
|
PET SCAN
• • •
|
PET SCAN COMMENT
|
|
|
|
|
CAT SCAN
|
DICTATION
|
|
CAT SCAN
• • •
|
CAT SCAN COMMENT
|
|
|
|
|
MRI
|
DICTATION
|
|
MRI
• • •
|
MRI COMMENT
|
|
|
|
|
MRA (ARTERIOGRAM)
|
DICTATION
|
|
MRA
• • •
|
MRA COMMENT
|
|
|
|
|
COORDINATION OF CARE - MRV (VENOGRAM)
|
DICTATION
|
|
MRV (VENOGRAM)
• • •
|
MRV COMMENT
|
|
|
|
|
X-RAY
|
DICTATION
|
|
RADIOGRAPHS
• • •
|
RADIOGRAPH COMMENT
|
|
|
|
|
NUCLEAR SCANS
|
DICTATION
|
|
NUCLEAR SCANS
• • •
|
NUCLEAR SCAN COMMENT
|
|
|
|
|
ULTRASOUND
|
DICTATION
|
|
ULTRASOUND
• • •
|
ULTRASOUND COMMENT
|
|
|
|
|
SKIN TESTS
|
DICTATION
|
|
SKIN TESTS
• • •
|
COC- SKIN TESTS
|
|
|
|
|
RECENT PAIN MEDICATION PRESCRIBED
|
|
|
RECENT PAIN MEDICATION PRESCRIBED
|
RECENT PAIN MEDICATION PRESCRIBED DICTATION
|
|
MEDICATION EFFECTIVENESS
• • •
|
MEDICATION EFFECTIVENESS COMMENT
|
|
PAIN AGREEMENT DETAILS DISCUSSED
|
PAIN AGREEMENT DETAILS DISCUSSED COMMENT
|
|
PAIN MEDICATION PRESCRIBED STATEMENT
• • •
|
PAIN MEDICATION DICTATION
|
|
SHORT ACTING OPIOIDS
• • •
|
SHORT ACTING OPIOIDS COMMENT
|
|
LONG ACTING OPIOIDS
• • •
|
LONG ACTING OPIOIDS COMMENT
|
|
MUSCLE RELAXER/ANTI-SPASMOTIC
• • •
|
MUSCLE RELAXER/ANTI-SPASMOTIC COMMENT
|
|
ANTICONVULSANTS
• • •
|
ANTICONVULSANTS COMMENT
|
|
NON-STEROID ANTI-INFLAMMATORY
• • •
|
NON-STEROID ANTI-INFLAMMATORY COMMENT
|
|
OSTEOPOROSIS MEDICATIONS
• • •
|
OSTEOPOROSIS MEDICATIONS COMMENT
|
|
HEADACHE MEDICATION
• • •
|
HEADACHE MEDICATION COMMENT
|
|
ANTI-DEPRESSANT MEDICATIONS
• • •
|
ANTIDEPRESSANT MEDICATIONS COMMENT
|
|
|
|
|
COMPREHENSIVE PAIN DIAGNOSIS
|
|
|
PAIN DIAGNOSIS/PROBLEMS
|
DICTATION
|
|
ACUTE OROFACIAL PAIN
• • •
|
ACUTE OROFACIAL PAIN COMMENT
|
|
CHRONIC OROFACIAL PAIN
• • •
|
CHRONIC OROFACIAL PAIN COMMENT
|
|
ACUTE OCULAR PAIN
• • •
|
ACUTE OCULAR PAIN
|
|
CHRONIC OCULAR PAIN
• • •
|
CHRONIC OCULAR PAIN
|
|
PERIAURICULAR PAIN SYNDROME
• • •
|
PERIAURICULAR PAIN SYNDROME
|
|
ACUTE HEADACHE DISORDER
• • •
|
ACUTE HEADACHE DISORDER COMMENT
|
|
CHRONIC HEADACHE DISORDER
• • •
|
CHRONIC HEADACHE DISORDER COMMENT
|
|
ANTERIOR (VENTRAL) THROAT / LARYNGEAL PAIN SYNDROME
• • •
|
ANTERIOR (VENTRAL) THROAT/LARYNGEAL PAIN COMMENT
|
|
ACUTE NECK PAIN SYNDROME
• • •
|
ACUTE NECK PAIN SYNDROME COMMENT
|
|
CHRONIC NECK PAIN SYNDROME
• • •
|
CHRONIC NECK PAIN SYNDROME COMMENT
|
|
ACUTE RIGHT SHOULDER PAIN
• • •
|
ACUTE RIGHT SHOULDER PAIN COMMENT
|
|
ACUTE LEFT SHOULDER PAIN
• • •
|
ACUTE LT SHOULDER PAIN COMMENT
|
|
CHRONIC RIGHT SHOULDER PAIN
• • •
|
CHRONIC RT SHOULDER PAIN COMMENT
|
|
CHRONIC LEFT SHOULDER PAIN
• • •
|
CHRONIC LT SHOULDER PAIN COMMENT
|
|
ACUTE RIGHT ARM PAIN
• • •
|
ACUTE RT ARM PAIN COMMENT
|
|
ACUTE LEFT ARM PAIN
• • •
|
ACUTE LT ARM PAIN COMMENT
|
|
CHRONIC RIGHT ARM PAIN
• • •
|
CHRONIC RT ARM PAIN COMMENT
|
|
CHRONIC LEFT ARM PAIN
• • •
|
CHRONIC LT ARM PAIN COMMENT
|
|
ACUTE RIGHT ELBOW PAIN
• • •
|
ACUTE RT ELBOW PAIN COMMENT
|
|
ACUTE LEFT ELBOW PAIN
• • •
|
ACUTE LT ELBOW PAIN COMMENT
|
|
CHRONIC RIGHT ELBOW PAIN
• • •
|
CHRONIC RT ELBOW PAIN COMMENT
|
|
CHRONIC LEFT ELBOW PAIN
• • •
|
CHRONIC LT ELBOW PAIN COMMENT
|
|
ACUTE RIGHT FOREARM PAIN: 719.43
• • •
|
ACUTE RIGHT FOREARM PAIN COMMENT
|
|
ACUTE LEFT FOREARM PAIN: 719.43
• • •
|
ACUTE LT FOREARM PAIN COMMENT
|
|
CHRONIC RIGHT FOREARM PAIN: 719.43
• • •
|
CHRONIC RT FOREARM PAIN COMMENT
|
|
CHRONIC LEFT FOREARM PAIN: 719.43
• • •
|
CHRONIC LT FOREARM PAIN COMMENT
|
|
ACUTE RIGHT HAND PAIN
• • •
|
ACUTE RT HAND PAIN COMMENT
|
|
ACUTE LEFT HAND PAIN
• • •
|
ACUTE LEFT HAND PAIN COMMENT
|
|
CHRONIC RIGHT HAND PAIN
• • •
|
CHRONIC RT HAND PAIN COMMENT
|
|
CHRONIC LEFT HAND PAIN
• • •
|
CHRONIC LT HAND PAIN COMMENT
|
|
ACUTE MIDBACK PAIN SYNDROME
• • •
|
ACUTE MID BACK PAIN COMMENT
|
|
CHRONIC MID BACK PAIN SYNDROME
• • •
|
CHRONIC MID BACK PAIN COMMENT
|
|
ACUTE CHEST WALL PAIN
• • •
|
ACUTE CHEST WALL PAIN COMMENT
|
|
CHRONIC CHEST WALL PAIN
• • •
|
CHRONIC CHEST WALL PAIN COMMENT
|
|
ACUTE LOW BACK PAIN SYNDROME
• • •
|
ACUTE LOW BACK PAIN COMMENT
|
|
CHRONIC LOW BACK PAIN
• • •
|
CHRONIC LOW BACK PAIN COMMENT
|
|
ACUTE SACROCOCCYGEAL SPINE PAIN
• • •
|
ACUTE SACROCOCCYGEAL SPINE PAIN COMMENT
|
|
CHRONIC SACROCOCCYGEAL SPINE PAIN
• • •
|
CHRONIC SACROCOCCYGEAL SPINE PAIN COMMENT
|
|
ACUTE COCCYGEAL PAIN (COCCYDYNIA)
• • •
|
ACUTE COCCYGEAL PAIN COMMENT
|
|
CHRONIC COCCYGEAL PAIN (COCCYDYNIA)
• • •
|
CHRONIC COCCYGEAL PAIN (COCCYDYNIA) COMMENT
|
|
ACUTE ANAL/RECTAL PAIN
• • •
|
ACUTE ANAL/RECTAL PAIN COMMENT
|
|
CHRONIC ANAL/RECTAL PAIN
• • •
|
CHRONIC ANAL/RECTAL PAIN COMMENT
|
|
ACUTE PELVIC PAIN- FEMALE
• • •
|
ACUTE PELVIC PAIN- FEMALE COMMENT
|
|
ACUTE PELVIC PAIN- MALE
• • •
|
ACUTE PELVIC PAIN-MALE COMMENT
|
|
CHRONIC PELVIC PAIN- FEMALE
• • •
|
CHRONIC PELVIC PAIN- FEMALE COMMENT
|
|
CHRONIC PELVIC PAIN-MALE
• • •
|
CHRONIC PELVIC PAIN-MALE COMMENT
|
|
ACUTE GENITALIA/GROIN PAIN-FEMALE
• • •
|
ACUTE GENITALIA/GROIN PAIN-FEMALE COMMENT
|
|
ACUTE GENITALIA/GROIN PAIN-MALE
• • •
|
ACUTE GENITALIA/GROIN-MALE PAIN COMMENT
|
|
CHRONIC GENITALIA/GROIN PAIN-FEMALE
• • •
|
CHRONIC GENITALIA/GROIN PAIN-FEMALE COMMENT
|
|
CHRONIC GENITALIA/GROIN PAIN-MALE
• • •
|
CHRONIC GENITALIA/GROIN PAIN-MALE COMMENT
|
|
CHRONIC RIGHT HIP PAIN
• • •
|
CHRONIC RIGHT HIP PAIN COMMENT
|
|
CHRONIC LEFT HIP PAIN
• • •
|
CHRONIC LEFT HIP PAIN COMMENT
|
|
CHRONIC RIGHT THIGH PAIN
• • •
|
CHRONIC RIGHT THIGH PAIN COMMENT
|
|
CHRONIC LEFT THIGH PAIN
• • •
|
CHRONIC LEFT THIGH PAIN COMMENT
|
|
CHRONIC RIGHT KNEE PAIN
• • •
|
CHRONIC RIGHT KNEE COMMENT
|
|
CHRONIC LEFT KNEE PAIN
• • •
|
CHRONIC LEFT KNEE PAIN COMMENT
|
|
CHRONIC RIGHT LEG PAIN
• • •
|
CHRONIC RIGHT LEG PAIN COMMENT
|
|
CHRONIC LEFT LEG PAIN
• • •
|
CHRONIC LEFT LEG PAIN COMMENT
|
|
ACUTE RIGHT ANKLE PAIN
• • •
|
ACUTE RIGHT ANKLE PAIN COMMENT
|
|
ACUTE LEFT ANKLE PAIN
• • •
|
ACUTE LEFT ANKLE PAIN COMMENT
|
|
CHRONIC RIGHT ANKLE PAIN
• • •
|
CHRONIC RIGHT ANKLE PAIN COMMENT
|
|
CHRONIC LEFT ANKLE PAIN
• • •
|
CHRONIC LEFT ANKLE PAIN COMMENT
|
|
ACUTE RIGHT FOOT PAIN
• • •
|
ACUTE RIGHT FOOT PAIN COMMENT
|
|
ACUTE LEFT FOOT PAIN
• • •
|
ACUTE LEFT FOOT PAIN COMMENT
|
|
CHRONIC RIGHT FOOT PAIN
• • •
|
CHRONIC RIGHT FOOT PAIN COMMENT
|
|
CHRONIC LEFT FOOT PAIN
• • •
|
CHRONIC LEFT FOOT PAIN COMMENT
|
|
|
|
|
PAINFUL MUSCLE DISEASES
• • •
|
PAINFUL MUSCLE DISEASES COMMENT
|
|
|
|
|
PAIN RISKS OF TREATMENT
|
|
|
RISKS OF PAIN CONDITION EXPLAINED
|
|
|
RISK OF TREATMENT EXPLAINED
• • •
|
RISK OF TREATMENT EXPLAINED COMMENT
|
|
PREVENTION OF WORSENING OF PAIN CONDITION
• • •
|
PREVENTION OF WORSENING OF PAIN CONDITION COMMENT
|
|
|
|
|
COMPREHENSIVE NEUROLOGICAL DIAGNOSIS
|
|
|
NEURO DIAGNOSIS/PROBLEMS
|
|
|
DICTATION
|
New Field
|
|
CRANIAL NEUROPATHIES
• • •
|
CRANIAL NEUROPATHIES COMMENTS
|
|
DISEASE OF THE BRACHIAL PLEXUS
• • •
|
DISEASE OF THE BRACHIAL PLEXUS
|
|
DISEASE OF THE LUMBER PLEXUS
• • •
|
DISEASE OF THE LUMBER PLEXUS COMMENTS
|
|
PHANTOM LIMB SYNDROME
• • •
|
PHANTOM LIMB SYNDROME COMMENTS
|
|
NERVE ROOT COMPRESSION SYNDROME
• • •
|
NERVE ROOT COMPRESSION SYNDROME COMMENTS
|
|
ACQUIRED MONONEUROPATHIES OF THE UPPER EXTREMITY
• • •
|
ACQUIRED MONONEUROPATHIES OF THE UPPER EXTREMITY COMMENTS
|
|
ACQUIRED MONONEUROPATHIES OF THE LOWER EXTREMITY
• • •
|
ACQUIRED MONONEUROPATHIES OF THE LOWER EXTREMITY COMMENTS
|
|
INFECTIOUS MONONEUROPATHY
• • •
|
INFECTIOUS MONONEUROPATHY COMMENTS
|
|
NUTRITION-RELATED MONONEUROPATHY
• • •
|
NUTRITION-RELATED MONONEUROPATHY COMMENTS
|
|
SYSTEMIC DISEASE MONONEUROPATHY
• • •
|
SYSTEMIC DISEASE MONONEUROPATHY COMMENTS
|
|
TOXIC MONONEUROPATHY
• • •
|
TOXIC MONONEUROPATHY COMMENT
|
|
VASCULITIC MONONEUROPATHY
• • •
|
VASCULITIC MONONEUROPATHY COMMENT
|
|
MONONEUROPATHY MULTIPLEX
• • •
|
MONONEUROPATHY MULTIPLEX COMMENT
|
|
POLYNEUROPATHY
• • •
|
POLYNEUROPATHY COMMENT
|
|
AUTONOMIC NERVOUS SYSTEM DISORDERS
• • •
|
AUTONOMIC NERVOUS SYSTEM DISORDERS COMMENTS
|
|
SEVERE BURNING DISTAL FINGERTIPS WITH WARMING
• • •
|
SEVERE BURNING DISTAL FINGERTIPS WITH WARMING COMMENT
|
|
HYPERHYDROSIS
• • •
|
HYPERHYDROSIS COMMENT
|
|
LIVIDO RETICULARI
• • •
|
LIVIDO RETICULARI COMMENT
|
|
DISEASES ASSOCIATED WITH AUTONOMIC DYSFUNCTION
• • •
|
DISEASES ASSOCIATED WITH AUTONOMIC DYSFUNCTION
|
|
DISEASES OF THE NEUROMUCULAR JUNCTION
• • •
|
DISEASES OF THE NEUROMUCULAR JUNCTION COMMENT
|
|
INHERITED MUSCLE DISEASE
• • •
|
INHERITED MUSCLE DISEASE
|
|
MYOPATHY
• • •
|
MYOPATHY COMMENT
|
|
ACQUIRED METABOLIC DISEASES OF THE NERVOUS SYSTEM
• • •
|
ACQUIRED METABOLIC DISEASES OF THE NERVOUS SYSTEM COMMENT
|
|
MOTOR NEURON DISEASE
• • •
|
MOTOR NEURON DISEASE COMMENT
|
|
DEVELOPMENTAL ABNORMALITIES OF THE NERVOUS SYSTEM
• • •
|
DEVELOPMENTAL ABNORMALITIES OF THE NERVOUS SYSTEM COMMENT
|
|
SPINAL CORD DISEASE
• • •
|
SPINAL CORD DISEASE COMMENT
|
|
CEREBROSPINAL FLUID DISORDERS
• • •
|
CEREBROSPINAL FLUID DISORDERS COMMENT
|
|
PARKINSON’S SYNDROME
• • •
|
PARKINSON’S SYNDROME COMMENT
|
|
CHOREA : GENERALIZED
• • •
|
CHOREA : GENERALIZED COMMENT
|
|
DYSTONIA : FOCAL
• • •
|
DYSTONIA : FOCAL COMMENT
|
|
DYSKINESIA
• • •
|
DYSKINESIA COMMENT
|
|
TREMOR
• • •
|
TREMOR COMMENT
|
|
TICS
• • •
|
TICS COMMENT
|
|
MYOCLONUS
• • •
|
MYOCLONUS COMMENT
|
|
PSYCHOGENIC MOVEMENT DISORDER
• • •
|
PSYCHOGENIC MOVEMENT DISORDER COMMENT
|
|
DEMYLINATION DISORDER
• • •
|
DEMYLINATION DISORDER
|
|
EPILEPSY
• • •
|
EPILEPSY COMMENT
|
|
VASCULAR DISORDERS
• • •
|
VASCULAR DISORDERS COMMENT
|
|
SYNCOPE
• • •
|
SYNCOPE COMMENT
|
|
STROKE SYNDROMES
• • •
|
STROKE SYNDROMES COMMENT
|
|
DELIRIUM SECONDARY TO BRAIN DAMAGE (F06)
• • •
|
DELIRIUM SECONDARY TO BRAIN DAMAGE COMMENT
|
|
AMNESTIC DISORDER SECONDARY TO TRAUMA: NOT DRUG OR ALCOHOL
• • •
|
AMNESTIC DISORDER SECONDARY TO TRAUMA: NOT DRUG OR ALCOHOL COMMENT
|
|
DELIRIUM : PSYCHOACTIVE SUBSTANCE ALCOHOL, BENZO, CANNABIS, STIMULANT, NICOTINE (F1X.9)
• • •
|
DELIRIUM : PSYCHOACTIVE SUBSTANCE ALCOHOL, BENZO, CANNABIS, STIMULANT, NICOTINE (F1X.9) COMMENT
|
|
DEMENTIA
• • •
|
DEMENTIA COMMENT
|
|
BRAIN TUMORS
• • •
|
BRAIN TUMORS COMMENT
|
|
SPINAL CORD TUMORS
• • •
|
SPINAL CORD TUMORS COMMENT
|
|
MENINGITIS
• • •
|
MENINGITIS COMMENT
|
|
HEREDITARY ATAXIA
• • •
|
HEREDITARY ATAXIA COMMENT
|
|
PARANEOPLASTIC NEUROMYOPATHY AND NEUROPATHY
• • •
|
PARANEOPLASTIC NEUROMYOPATHY AND NEUROPATHY COMMENT
|
|
|
|
|
NEUROLOGICAL
|
|
|
COC NEUROLOGICAL- PREVENTION/RISK MANAGEMENT TREATMENT AND ALTERNATIVES
|
|
|
PREVENTATIVE MEASURES
• • •
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RISK OF TREATMENT EXPLAINED
• • •
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RISKS ASSOCIATED WITH CONDITION COMMENT
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TREATMENT EXPLAINED
• • •
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TREATMENT EXPLAINED COMMENT
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PREVENTION OF WORSENING OF CONDITION
• • •
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PREVENTION OF WORSENING OF CONDITION COMMENT
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COMPREHENSIVE PSYCHIATRIC DIAGNOSIS
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COMPREHENSIVE PSHCHIATRIC DIAGNOSIS
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Mood Disorders-Unspecified (F9)
• • •
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MOOD DISORDERS-UNSPECIFIED COMMENT
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Neurotic Somatoform Disorders (F40.9)
• • •
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NEUROTIC SOMATOFORM DISORDERS (F40.9 COMMENT
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Anxiety Disorders (F 41)
• • •
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ANXIETY DISORDER COMMENT
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Adjustment (To Stress) Disorders (F43)
• • •
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ADJUSTMENT (TO STRESS) DISORDERS COMMENT
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Dissociative Conversion Disorder: Unspecified (44.9)
• • •
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DISSOCIATIVE CONVERSION DISORDER: UNSPECIFIED COMMENT
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Other Conversion Disorders (44.9)
• • •
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OTHER CONVERSION DISORDERS COMMENT
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Somatoform Autonomic Dysfunction (F45.3)
• • •
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SOMATOFORM AUTONOMIC DYSFUNCTION COMMENT
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Somatoform Disorders (F45.0)
• • •
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SOMATOFORM DISORDERS COMMENT
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Phobias
• • •
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PHOBIAS COMMENT
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Eating Disorders: Unspecified (F50)
• • •
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EATING DISORDERS: UNSPECIFIED COMMENT
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Sexual Dysfunction
• • •
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SEXUAL DYSFUNCTION COMMENT
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Personality Disorder
• • •
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PERSONALITY DISORDER COMMENT
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Mental Retardation
• • •
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MENTAL RETARDATION COMMENT
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TIC Disorder
• • •
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TIC DISORDER COMMENT
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Substance Disorder
• • •
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SUBSTANCE DISORDER COMMENT
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Schizo-Delusional Disorders
• • •
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SCHIZO-DELUSIONAL DISORDERS COMENT
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Pervasive Developmental Disorder
• • •
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PERVASIVE DEVELOPEMENTAL DISORDER COMMENT
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PSYCHIATRIC
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COORDINATION OF CARE-RISKS ASSOCIATED WITH PROGRESSION
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Discussed Risks Related To Progression Of Psychiatric Disease
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Risk Of Treatment Explained
• • •
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COC-RISKS OF TREATMENT COMMENT
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Discussion On Diagnosis And Prevention Of Disease Progression
• • •
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DISCUSSION ON DIAGNOSIS AND PREVENTION OF DISEASE PROGRESSION COMMENT
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COMPREHENSIVE MEDICAL DIAGNOSIS
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COMPREHENSIVE MEDICAL DIAGNOSIS
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Allergies
• • •
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ALLERGIES COMMENT
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Dermatological Disorders
• • •
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DERMATOLOGICAL DISORDERS COMMENT
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Infectious Diseases
• • •
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INFECTIOUS DISEASES COMMENT
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Neoplasm
• • •
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NEOPLASM COMMENT
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Diseases Of Blood
• • •
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DISEASES OF BLOOD COMMENT
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Cardiovascular Disease
• • •
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CARDIAVASCULAR DISEASE COMMENT
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Gastrointestinal Illness
• • •
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GASTROINTESTINAL ILLNESS COMMENT
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Gynecological Diseases
• • •
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GYNOCOLOGICAL DISEASES COMMENT
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Ophthalmologic Disease
• • •
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OPTHALMOLOGIC DISEASE COMMENT
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Otolaryngology
• • •
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OTOLARYNGOLGY COMMENT
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Pulmonary Disorders
• • •
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PULMONARY DISORDER COMMENT
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Comorbid Medical Functional Status
• • •
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COMORBID MEDICAL FUNCTIONAL STATUS COMMENT
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COC MEDICAL DIAGNOSIS
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COORDINATION OF CARE MEDICAL DIAGNOSIS
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RISK OF TREATMENT EXPLAINED
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PREVENTION OF PROGRESSION
• • •
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PREVENTION OF PROGRESSION COMMENT
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COORDINATION OF CARE DIAGNOSTIC TESTS ORDERED
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COC DIAGNOSTIC TEST ORDERED
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MEDICAL NECESSITY DIAGNOSTIC TEST
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Medical Necessity Diagnostic Test
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The Purpose Of Ordering Diagnostic Studies
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NEURODIAGNOSTIC STUDIES
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NEURODIAGNOSTIC STUDIES
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Nerve Conduction Studies/EMG
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NERVE CONDUCTION STUDIES COMMENT
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WAKING EEG
• • •
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WAKING EEG COMMENT
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SLEEP DEPRIVED EEG
• • •
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SLEEP DEPRIVED EEG COMMENT
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POLYSOMNOGRAM
• • •
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POLYSOMNOGRAM COMMENT
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MULTIPLE SLEEP LATENCIES
• • •
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MULTIPLE SLEEP LATENCIES COMMENT
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COC- CARDIAC STUDIES
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CARDIAC STUDIES ORDERED
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TRANS TRORACIC CARDIAC ULTRASOUND
• • •
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TRANS TRORACIC CARDIAC ULTRASOUND COMMENT
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TRANS ESOPHAGEAL CARDIAC ULTRASOUND
• • •
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TRANS ESOPHAGEAL CARDIAC ULTRASOUND COMMENT
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BUBBLE ECHO
• • •
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BUBBLE ECHO COMMENT
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12 LEAD EKG (ELECTROCARDIOGRAM)
• • •
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12 LEAD EKG COMMENT
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24 HOUR HOLTER MONITOR
• • •
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24 HOUR HOLTER MONITOR COMMENT
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PULMONARY DIAGNOSTIC TESTS
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PULMONARY DIAGNOSTIC TESTS ORDERED
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PULMONARY DIAGNOSTIC TEST
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ARTERIAL BLOOD GASES
• • •
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ARTERIAL BLOOD GASES COMMENT
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OVERNIGHT OXIMETRY READING
• • •
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OVERNIGHT OXIMETRY READING COMMENT
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LABS
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LAB WORK ORDERED
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BLOOD WORK
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BLOOD WORK
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BLOOD WORK
• • •
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BLOOD WORK COMMENT
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ANTICONVULSANT BLOOD LEVELS
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ANTICONVULSANT BLOOD LEVELS
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ANTICONVULSANT BLOOD LEVELS RESULTS
• • •
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ANTICONVULSANT BLOOD LEVELS COMMENTS
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OPIATE SERUM BLOOD LEVELS
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COC- OPIATE SERUM DRUG LEVELS
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OPIATE SERUM DRUG LEVELS
• • •
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OPIATE SERUM DRUG LEVELS COMMENTS
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COC- HARMONE/ENZYME ASSAYS
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COC- HORMONE/ENZYME ASSAYS
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HORMONE/ENZYME ASSAYS
• • •
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HORMONE/ENZYME ASSAYS COMMENT
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COC-MRI
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New Field
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COC- MRI
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MRI
• • •
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MRI COMMENT
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COC- MRA
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New Field
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COC- MRA (ARTERIOGRAM)
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MRA
• • •
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MRA COMMENT
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COC-MRV
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COC-MRV (VENOGRAM)
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MRV (VENOGRAM)
• • •
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MRV COMMENT
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COC-PET SCAN
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COC- PET SCAN
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PET SCAN
• • •
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PET SCAN COMMENT
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COC-CAT SCAN
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COC- CAT SCAN
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CAT SCAN
• • •
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CAT SCAN COMMENT
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XRAY
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New Field
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COC- X-RAY
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X-RAY
• • •
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X-RAY COMMENT
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COC-NUCLEAR SCANS
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COC- NUCLEAR SCANS
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NUCLEAR SCANS
• • •
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NUCLEAR SCAN COMMENT
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COC-ULTRASOUND
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COC- ULTRASOUND
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ULTRASOUND
• • •
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ULTRASOUND COMMENT
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COC- SKIN TESTS
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COC- SKIN TEST
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SKIN TEST
• • •
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SKIN TEST COMMENT
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COORDINATION OF CARE- MEDICATIONS
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COC - MEDICATIONS
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TREATMENT OPTIONS TO MEDICATION
• • •
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OPTIONS TO MEDICATION COMMENT
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PAIN MEDICATION TREATMENT OUTCOME DOCUMENTATION OF RECENT PAIN MEDICATION PRESCRIBED
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RECENT PAIN MEDICATION PRESCRIBED
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DICTATION
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SHORT ACTING OPIOIDS
• • •
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SHORT ACTING OPIOIDS COMMENT
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LONG ACTING OPIOIDS
• • •
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LONG ACTING OPIOIDS COMMENT
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MUSCLE RELAXER/ANTI-SPASMOTIC
• • •
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MUSCLE RELAXER/ANTI-SPASMOTIC COMMENT
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ANTICONVULSANTS
• • •
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ANTICONVULSANTS COMMENT
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NON-STEROID ANTI-INFLAMMATORY
• • •
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NON-STEROID ANTI-INFLAMMATORY COMMENT
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OSTEOPOROSIS MEDICATIONS
• • •
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OSTEOPOROSIS MEDICATIONS COMMENT
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HEADACHE MEDICATION
• • •
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HEADACHE MEDICATION COMMENT
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ANTI-DEPRESSANT MEDICATIONS
• • •
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ANTIDEPRESSANT MEDICATIONS COMMENT
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SLEEPERS
• • •
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SLEEPERS COMMENTS
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ERECTILE DYSFUNCTION
• • •
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ERECTILE DYSFUNCTION COMMENT
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MEDICATION EFFECTIVENESS
• • •
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MEDICATION EFFECTIVENESS COMMENT
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MEDICATION-PURPOSE, INDICATION
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OPIATES, HYPNOTICS, ANTI-ANXIETY MEDS
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MEDICATION PRESCRIBED TODAY
• • •
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MEDICATION PRESCRIBED
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MEDICATION PRESCRIBED TODAY COMMENT
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INDICATION-PAIN MED
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Indication For Pain Medication
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MEDICAL NECESSITY- PAIN MED
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Medical Necessity For Pain Medication
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MEDICATION CONTRAINDICATION
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Medication- Contraindications To Prescribing Opioids
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ALTERNATIVES TO TREATMENT- PAIN MED
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Alternatives To Treatment With Medication And Options Of Type Of Medication
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OPIOID RISKS- PAIN MED
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Opioid Risks, Interactions, Complications
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PAIN AGREEMENT
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Pain Agreement Details Discussed
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PAIN AGREEMENT DETAILS DISCUSSED
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PAIN AGREEMENT DETAILS DISCUSSED
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COORDINATION OF CARE- THERAPY
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Therapy
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THERAPY: PAIN DECREASED
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THERAPY: PAIN DECREASED COMMENT
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THERAPY: FUNCTION IMPROVED
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THERAPY: FUNCTION IMPROVED COMMENT
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THERAPY ORDERED
• • •
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THERAPY ORDERED COMMENT
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ORTHOTIC CONSULT OPTIONS
• • •
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ORTHOTIC CONSULT OPTIONS COMMENT
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Durable Medical Equipment
• • •
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Durable Medical Equipment Comment
|
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Home Traction
• • •
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Home Traction Comment
|
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TREATMENT ALTERNATIVES TO THERAPY
• • •
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TREATMENT ALTERNATIVES TO THERAPY
|
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INDICATION FOR THERAPY
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Indication For Therapy Comment
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MEDICAL NECESSITY FOR THERAPY
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MEEDICAL NECESSITY DOCUMENTATION COMMENT
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COORDINATION OF CARE- PROCEDURES
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DICTATION
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COC- PROCEDURES
|
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OUTCOMES
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COC- OUTCOME STUDIES ON RECENTLY PERFORMED PROCEDURES
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OUTCOME COMMENT
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PROCEDURES
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PROCEDURES DICTATION
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WHERE WAS PROCEDURE PERFORMED?
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PROCEDURES
• • •
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PROCEDURES DICTATION
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PROCEDURES AND IV SEDATION OPTIONS
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PROCEDURES AND IV SEDATION OPTIONS COMMENT
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CONTRAST OPTION
|
CONTRAST OPTION COMMENT
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COORDINATION OF CARE- INTERVENTIONAL PROCEDURES
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COORDINATION OF CARE- INTERVENTIONAL PROCEDURES
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COC-INTERVENTIONAL PAIN PROCEDURES
• • •
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COC- INTERVENTIONAL PAIN PROCEDURES COMMENT
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PURPOSE/INDICATION-PROCEDURE
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PURPOSE, INDICATION & MEDICAL NECESSITY OF THE PROCEDURES WERE DISCUSSED
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INFORMED CONSENT- PROCEDURE
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PROCEDURE INFORMED CONSENT
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REASON FOR PROCEDURE
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REASON FOR THE PROCEDURE
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REASON FOR PROCEDURE COMMENT
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MEDICAL NECESSITY- PROCEDURE
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MEDICAL NECESSITY OF PROCEDURES
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REFERRALS
|
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COORDINATION OF CARE- REFERRALS
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TREATMENT OPTION: ENT SURGERY REFERRAL
• • •
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REFERRALS- ENT COMMENT
|
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REFERRAL- NEUROSURGICAL TREATMENT
• • •
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REFERRALS- NEUROSURGICAL COMMENT
|
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REFERRAL ORTHOPEDIC SURGERY
• • •
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REFERRALS- ORTHO COMMENT
|
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REFFERAL- PAIN MANAGEMENT
• • •
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REFERRALS- PAIN COMMENT
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REFERRAL- PSYCHIATRIC SECOND OPINION
• • •
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REFERRALS- PSYCHIATRIC COMMENT
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REFERRAL- GENERAL MEDICAL
• • •
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REFERRALS- GENERAL MEDICAL COMMENT
|
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REFERRAL: SECOND OPINION-NEUROLOGICAL CONDITION
• • •
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REFERRALS-NEUROLOGICAL COMMENT
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FORMS
|
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COORDINATION OF CARE- FORMS
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FORMS REVIEWED, DISCUSSED COMPLETED
• • •
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FORMS COMMENT
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WORK STATUS
|
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COORDINATION OF CARE- WORK STATUS
|
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CURRENT WORK SITUATION
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WORK SITUATION COMMENT
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WORK STATUS
|
LEGAL WORK STATUS COMMENT
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COORDINATION OF CARE RESTRICTIONS
|
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COORDINATION OF CARE RESTRICTIONS
|
RESTRICTIONS DICTATION
|
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CERVICAL RESTRICTIONS
• • •
|
CERVICAL RESTRICTIONS COMMENT
|
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LUMBAR RESTRICTIONS
• • •
|
LUMBAR RESTRICTIONS COMMENT
|
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WORKER’S COMPENSATION RATING
|
WORKER’S COMPENSATION RATING COMMENT
|
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WORKER’S COMPENSATION RATING
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PERSONAL INJURY RATING
|
PERSONAL INJURY RATING COMMENT
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PERSONAL INJURY RATING
|
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DISCHARGE
|
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COORDINATION OF CARE DISCHARGE PLANNING
|
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FOLLOW UP
• • •
|
FOLLOW UP DICTATION
|
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DISCHARGE PLANNING
• • •
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DISCHARGE PLANNING DICTATION
|
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AUTHORIZATION
• • •
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