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***Please make sure there is a REASON for this visit in the appointment (above)
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Clinical Provider
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Subjective- Explain medical necessity or use quick selects below
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Medical Necessity Switch
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Medical Necessity
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Medical Necessity Explanations (Quick Select)
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Medical Necessity Explanations (written)
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Subjective Quick Selections
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He/She complains of <Common complaints>
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Additional Comments
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HPI for today's issue (Required for 99309-10)
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Location: 'The location of today's complaint is'
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Severity
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location comments:
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Severity comments
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Quality
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Context
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Quality comments
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Context: (how did it happen?)
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Associated Sx's: 'Today's issue is also associated with: (input here)'
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Modifying factors
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Associated symptoms: (input here)
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Modifying factors: (input here)
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Timing options
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Timing : 'This issue started:( input here ) '
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Additional Comments
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Add image
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Add image here (or later in Objective)
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Normal ROS
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Unable to obtain ROS due to unreliable historian
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Detailed ROS
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General [-]
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General [+]
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General (NEG) Comments
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General (POS) Comments
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Skin [-]
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Skin [+]
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Skin (NEG) Comments
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Skin (POS) Comments
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HEENT [-]
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HEENT [+]
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HEENT Comments
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HEENT (POS) Comments
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Neck [-]
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Neck [+]
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Neck Comments
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Neck (POS) Comments
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Cardiovascular [-]
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Cardiovascular [+]
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CV Comments
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Cardiovascular (POS) Comments
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Respiratory [-]
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Respiratory [+]
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Resp Comments
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Respiratory (POS) Comments
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GI [-]
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GI [+]
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GI Comments
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GI (POS) Comments
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Urinary [-]
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Urinary [+]
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Urinary Comments
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Urinary (POS) Comments
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Genital (Male) [-]
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Genital (Male) [+]
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Genital (Male) Comments
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Genital Male (POS) Comments
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Genital (Female) [-]
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Genital (Female) [+]
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Genital (Female) Comments
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Genital Female (POS) Comments
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Periph. Vasc. [-]
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Periph. Vasc. [+]
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Periph. Vasc. Comments
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Periph. Vasc. (POS) Comments
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MSK [-]
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MSK [+]
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MSK Comments
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MSK. (POS) Comments
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Neurologic [-]
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Neurologic [+]
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Neuro Comments
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Neurologic (POS) Comments
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Endocrine [-]
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Endocrine [+]
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Endo Comments
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Endocrine (POS) Comments
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Psychiatric [-]
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Psychiatric [+]
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Psychiatric Comments
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Psychiatric (POS) Comments
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Outcome MD Questionnaire Answers
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Pain Management Documentation (Required for OUTPATIENT Sched II Rx)
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Required documentation for OUTPATIENT controlled Rx
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Prescription Drug Monitoring Program reviewed. https://florida.pmpaware.net/
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7-day supply for Acute Pain (exception from 3-day Supply)
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Indicate "acute pain exception" on the prescription
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Exceptions to acute pain prescribing limits
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History of Drug abuse or dependence?
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History of Drug Abuse (comments)
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Evaluations and consultations
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Evaluations and consultations (comment)
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Treatment Objectives
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Treatment objectives (comment)
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Risks and Benefits discussed
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Treatment (date, Rx type, dosage, & quantity prescribed)
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Results of any drug testing
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Instructions and Agreements
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Periodic reviews
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