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APPT START TIME (Free Text)
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APPT END TIME (Free-Text)
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WHAT SERVICE ARE YOU PERFORMING?
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INITIAL EVALUTION
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FOLLOW UP
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SELECT PROVIDER TYPE
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SELECT PROVIDER TYPE
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MEDICAL - INITIAL VISIT
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MEDICAL - FU (99214/5)
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THERAPIST - INITIAL VISIT
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THERAPIST - FU (90832,4,7)
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HISTORY OF PRESENT ILLNESS
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HPI "Pt-name is yo m/f presenting for CC." + (Free-Text)
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PROBLEMS
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HPI PROBLEM ASSISTANT #1
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PROBLEM #1 (free-text)
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Problem 1 status
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DESCRIPTORS (loc/dur/tim)
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SEVERITY SCALE (sev/qual/context)
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ALLEVIATING / AGGRAVATING FACTORS
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HPI PROBLEM ASSISTANT #2
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PROBLEM #2 (free-text)
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Problem 2 status
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DESCRIPTORS 2 (loc/dur/tim)
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SEVERITY SCALE 2 (sev/qual/context)
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ALLEVIATING / AGGRAVATING FACTORS 2
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HPI PROBLEM ASSISTANT #3
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PROBLEM #3 (free-text)
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Problem 3 status
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DESCRIPTORS (loc/dur/tim) 3
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SEVERITY SCALE (sev/qual/context) 3
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ALLEVIATING / AGGRAVATING FACTORS 3
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HPI PROBLEM ASSISTANT #4
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PROBLEM #4 (free-text)
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Problem 4 status
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DESCRIPTORS (loc/dur/tim) 4
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SEVERITY SCALE (sev/qual/context) 4
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ALLEVIATING / AGGRAVATING FACTORS 4
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ASSESSMENT CARRIED-FORWARD FROM PLAN
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PSYCHOTHERAPY
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PROBLEMS ADDRESSED
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INTERVENTIONS USED
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PATIENT RESPONSE
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90791 Code Added
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INTERACTIVE COMPLEXITY ADD-ON (THIN)
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PROBLEMS ADDRESSED
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INTERVENTIONS USED
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PATIENT RESPONSE
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16-37 MINUTES SPENT ON THERAPY
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PSYCHOTHERAPY ADD ON
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PROBLEMS ADDRESSED
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INTERVENTIONS USED
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PATIENT RESPONSE
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16-37 MINUTES SPENT ON THERAPY
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Select Time Spent
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REVIEW OF SYSTEMS
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CONSTITUTIONAL (-weak, -fever/chill)
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MUSCULOSKELETAL (-stiff,-tenderness)
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HEENT (-headache,-nosebleeds)
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NEUROLOGICAL (-weakness,-tremors)
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CARDIOVASCULAR (-chestpain,-palpitations)
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PULMONARY (-cough,-sputum)
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GASTROINTESTINAL (-diarrhea,-nausea)
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GENITOURINARY (-polyuria,-urgency)
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ENDOCRINE (-excess thirst,-cold intolerance)
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INTEGUMENTARY (-rash,-itching)
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Additional Information:
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REVIEW OF SYSTEMS (FU)
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CONVERT TO 10 POINT ROS
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CONSTITUTIONAL (-weak, -fever/chill)
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MUSCULOSKELETAL (-stiff,-tenderness)
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HEENT (-headache,-nosebleeds)
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NEUROLOGICAL (-weakness,-tremors)
• • •
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CARDIOVASCULAR (-chestpain,-palpitations)
• • •
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PULMONARY (-cough,-sputum)
• • •
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GASTROINTESTINAL (-diarrhea,-nausea)
• • •
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GENITOURINARY (-polyuria,-urgency)
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ENDOCRINE (-excess thirst,-cold intolerance)
• • •
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INTEGUMENTARY (-rash,-itching)
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