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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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Medical Decision Making (Comment)
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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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***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/Plan Boxes
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Assessment/Problem List (separated boxes)
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Subsequent Care Comments (separate boxes)
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Problem #1
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Assessment/Plan
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Subsequent Care Comments
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Problem #2
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Assessment/Plan
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Subsequent Care Comments
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Problem #3
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Assessment/Plan
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Subsequent Care Comments
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Problem #4
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Assessment/Plan
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Subsequent Care Comments
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Problem #5
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Assessment/Plan
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Subsequent Care Comments
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Problem #6
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Need more Assessment Boxes?
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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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Common Assessment/Plans
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Afib
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Atrial fibrillation Comments (optional)
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ASCAD
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ASCAD comments (optional)
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Anemia (stable)
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Anemia Comments (optional)
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Chronic Pain
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Chronic Pain Comments (optional)
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COPD
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COPD Comments (optional)
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Dementia (senile)
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Dementia Comments (optional)
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DM
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DM Comments (optional)
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Dysphagia
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Dysphagia Comments (optional)
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GERD
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GERD Comments (optional)
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HTN
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HYPERTENSION Comments (optional)
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HPLD
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HPLD Comments (optional)
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Hypothyroidism
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Hypothyroid Comments (optional)
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Joint Replacement
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Joint Replacement Comments (optional)
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Needs Assistance w/ Personal Care
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Needs Assistance Comments (optional)
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Obesity
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Obesity Comments (optional)
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Osteoporosis
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Osteoporoses Comments (optional)
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PAD
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PAD Comments (optional)
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Repeated falls
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Falls Comments (optional)
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History of UTI
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UTI Comments (optional)
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Walking Difficulty
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Walking Difficulty Comments (optional)
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Weakness
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Weakness Comments (optional)
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Other
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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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Comments
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Medical Decision Making
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Supportive Documentation
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Medical Decision making HIGH Complexity 2 of 3
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PFSH was reviewed (required for 99310)
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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 patient MACRO/Auto Text
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Timely Follow Up Needed; MACRO/Autotext
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E-signed by:
• • •
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High Risk of complications
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Dictation Disclaimer
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Add Image
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HB21 compliance
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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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