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TODAY'S PROVIDER
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REASON FOR VISIT
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Reason for Visit
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PATIENT CONSENT
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Patient Consent (Turn ON for Telemedicine)
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Patient consent given for telemedicine by:
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Vitals Obtained
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Start Time
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Start Time
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VITALS (Auto-filled)
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Blood Pressure
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Blood Pressure (auto-filled)
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Systolic Result
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Diastolic Result
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HOSPITAL / ER ADMISSION DETAILS
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1. Hospital / ER Discharge Summary Reviewed
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2. If hospital admission, was this a readmission?
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3. Reason for Admission / ER Visit
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4. Date of Admission / ER Visit (MM/DD/YYYY)
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5. Admission / ER Time Details
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If other on Admission/ER Visit Details, explain:
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6. Did patient consider going to urgent care?
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7. Did you contact your PCP prior to going to hospital / ER?
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8. Were you sent to the hospital/ER by your PCP?
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9. Based on clinician's assessment, if admission/ER visit was avoidable, list reasons why?
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10. What other factors contributed to hospital admission or ER visit?
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11. Does patient have any of the following chronic conditions?
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12. Does pt have any urgent concerns that need to be addressed during this visit?
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13. Do you have a follow-up appointment scheduled with your PCP?
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14. Does patient have necessary DME?
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15. Does patient have home health?
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16. Is patient receiving PT/OT?
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17. Is patient receiving behavioral health services?
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18. Is patient receiving substance / alcohol use rehab services?
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19. Is patient under case management?
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SPECIALISTS PATIENT IS SEEING
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20. Patient is seeing following specialist(s):
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If other, what type of specialist?
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MEDICATION REVIEW & MEDICAL PROBLEMS
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21. Medications & Medical Problems (use dictation, e.g. "lisinopril for HTN")
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22. Were you prescribed new medications at the hospital?
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If yes, explain:
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23. Medication Adherence before Admission / ER Visit
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24. Medication Adherence (current)
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25. Medications reconciled with patient/caregiver (CPT2)
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All medication reviewed? (CPT 2)
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25. No new medications prescribed on this visit. (defaulted)
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I have personally reviewed patient medication list. (defaulted)
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REVIEW OF SYSTEMS
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CONST
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Notes
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EYES
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Notes
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ENMT
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Notes
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CV
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Notes
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RESP
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Notes
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GI
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Notes
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GU
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Notes
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MUSC
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Notes
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SKIN
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Notes
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PSYCH
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Notes
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NEURO
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Notes
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Other ROS Notes
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PHYSICAL EXAM (all default to normal)
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GEN
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Abnormal
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EYES
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Abnormal
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ENMT
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Abnormal
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NECK
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Abnormal
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RESP
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Abnormal
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CARDIO
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Abnormal
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GI
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Abnormal
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MUSCULOSKELETAL
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Abnormal
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SKIN
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Abnormal
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PSYCH
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Abnormal
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NEURO
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Abnormal
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Clinician Notes
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DEPRESSION SCREENING (PHQ2/PHQ9)
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In the past month, have you often been bothered by feeling down, depressed, or hopeless?
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In the past month, have you often been bothered by having little interest in doing things?
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If yes to either, please explain.
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PAST HISTORY OF TREATED DEPRESSION
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Have you ever been treated for depression by a physician or other type of clinician?
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Notes Section
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Depression Screening Completed (defaulted to ON, CPT2 Code)
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If patient answers yes to either question, tap on PHQ9 button.
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PHQ-9
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1. Little interest or pleasure in doing things
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2. Feeling down, depressed, or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself or that you have let yourself or family down
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7. Trouble concentrating on things, such as reading the newspaper or watching TV
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8. Moving or speaking so slowly that other people could notice or being fidgety or restless
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9. Thoughts that you would be better off dead, or of hurting yourself
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Does the patient have at least 5 of the 9 symptoms above?
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If YES, consider Dx of Major Depression
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If NO, consider unspecified adjustment disorder.
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Add numbers in ( ) for PHQ9 Total Score
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TOTAL PHQ-9 SCORE
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Depression Severity Results
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ASSESSMENT & PLAN
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1. Assessment & Plan
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2. Assessment & Plan
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3. Assessment & Plan
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4. Assessment & Plan
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5. Assessment & Plan
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6. Assessment & Plan
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7. Assessment & Plan
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8. Assessment & Plan
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9. Assessment & Plan
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10. Assessment & Plan
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REFERRALS / CONCERNED PT ENCOUNTER
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TURN ON for Referrals & Concerned Pt. Encounter
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Notes to PCP:
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