|
Returning Visit
|
New Patient
|
|
ReExam - Continued care
|
Est Pt Visit - New Prob
|
|
Est Pt Visit - Face to Face 99213
|
Est Pt Visit - Exacerbation
|
|
Elective Care
|
Est Pt Visit - New Episode Prior
|
|
Location(s)
|
Data Reviewed
• • •
|
|
General Hx
|
|
|
PROBLEM #1
|
|
|
Referring Doctor
|
|
|
Problem #1
• • •
|
Notes:
|
|
|
Prior Episodes
|
|
Pain Range
• • •
|
Symptom(s) at Onset
• • •
|
|
Constant Symptom(s)
• • •
|
Intermittent Symptom(s)
• • •
|
|
No Apparent Reason
|
Mechanism of Injury
|
|
Duration
|
|
|
Pain Description
• • •
|
Improving/unchanging/Worsening
• • •
|
|
Constant/Intermittent
• • •
|
Disturbed Sleep
|
|
Activity Intolerances
|
|
|
BETTER
|
|
|
Better Always
• • •
|
Better Sometimes
• • •
|
|
Better Other
|
|
|
WORSE
|
|
|
Worse Always
• • •
|
Worse Sometimes
• • •
|
|
Worse Other
|
|
|
Denies Systemic
|
Negative Systemic
• • •
|
|
Positive Systemic
• • •
|
Previous Treatments
• • •
|
|
PROBLEM #2
|
Problem #2
|
|
Problem #2
• • •
|
Notes:
|
|
|
Prior Episodes
|
|
Pain Range
• • •
|
Symptom(s) at Onset
• • •
|
|
Constant Symptom(s)
• • •
|
Intermittent Symptom(s)
• • •
|
|
No Apparent Reason
|
Mechanism of Injury
|
|
Duration
|
|
|
Pain Descriptors
• • •
|
Improving/unchanging/Worsening
• • •
|
|
Constant/Intermittent
• • •
|
|
|
Activity Intolerances
|
|
|
BETTER #2
|
|
|
Better Always
• • •
|
Better Sometimes
• • •
|
|
Better Other
|
|
|
WORSE #2
|
|
|
Worse Always
• • •
|
Worse Sometimes
• • •
|
|
Worse Other
|
Previous Treatments
• • •
|
|
PROBLEM #3
|
Problem #3
|
|
Problem #3
• • •
|
Notes:
|
|
|
Prior Episodes
|
|
Pain Range
• • •
|
Symptom(s) at Onset
• • •
|
|
Constant Symptom(s)
• • •
|
Intermittent Symptom(s)
• • •
|
|
No Apparent Reason
|
Mechanism of Injury
|
|
Duration
|
|
|
Pain Descriptors
• • •
|
Improving/unchanging/Worsening
• • •
|
|
Constant/Intermittent
• • •
|
|
|
Activity Intolerances
|
|
|
BETTER #3
|
|
|
Better Always
• • •
|
Better Sometimes
• • •
|
|
Better Other
|
|
|
WORSE #3
|
|
|
Worse Always
• • •
|
Worse Sometimes
• • •
|
|
Worse Other
|
Previous Treatments
• • •
|
