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LABS/RADIOLOGY- Update new findings here
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Lab comments
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CBC
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Date of Service
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CBC- Reviewed WNL
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WBC
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Hgb/Hct
/
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Platelets
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CBC comments
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BMP
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Date of Service
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BMP- Reviewed WNL
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Na
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Potassium (K)
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CO2
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Calcium
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BUN
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Cr
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Glucose
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BMP comments
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PT/INR
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Date of Service
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PT/INR- Reviewed WNL
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PT/INR
/
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PT/INR Comments
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Rad Reports
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Date of Service
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Rad Report
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Rad Report comments
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Medical Decision Making
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99309/99310 Supportive Documentation
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PFSH was reviewed (required for 99310)
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Medical Decision making HIGH Complexity 2 of 3
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Extensive Mangement options
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Time Spent (Minutes)
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Extensive Data review
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Input minutes here
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High Risk of complications
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PLAN
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High Risk Status (Task SolCtr to ADD or REMOVE HIGH RISK scheduling when turning On/ OFF)
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High Risk Scheduling Comments (hidden from documentation)
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APP's-PLEASE switch OFF attestations if left ON from previous note
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Dr Bob Attestation
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Dr Jim Attestation
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***NEW / URGENT Issue(s)-
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ONLY for up to 2 visits. COPY/PASTE to RECENT ISSUE if ongoing
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New Issue DIAGNOSIS
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Diagnosis comments
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New Issue (Multiple)
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New Issue (Multiple) Comments
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New Issue (Multiple)
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New Issue (Multiple) Comments
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Recent Issue (Ongoing from a previous 'New Issue') - Copy/Paste old 'New Issues' here; No date stamp
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This Section is reserved for pasting issues that were previously 'New'
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Recent Issue (Carry down previous 'New Issues')
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Recent issue subsequent comments
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Recent Issue (Carry down previous 'New Issues')
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Recent issue subsequent comments
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Recent Issue (Carry down previous 'New Issues')
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Recent issue subsequent comments
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Assessment/Plan
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ASSESSMENT/PLAN (single box summary)
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Assessment/Problem List (separated boxes)
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Subsequent Care Comments
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Other
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Obtain labs every <days of the week>
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Days of the week
• • •
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Comment
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VTE prophylaxis
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Blood thinners
• • •
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Comment
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Additional Numerical Assmnt/Prblem List
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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Assessment/Plan
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Subsequent Care Comments
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High Risk patient MACRO/Auto Text
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Timely Follow Up Needed; MACRO/Autotext
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Dictation Disclaimer
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Add Image
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HB21 Compliance
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Add an image here
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Add Image Here
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