如何制作醫學主題模板第一頁，共三十五頁，編輯于2023年，星期二ProblemAfamiliarlament...

“NomatterhowmuchIwriteinmyhistoryandphysicalexamnote,Ineverseemtodocumentenoughtosubstantiateahighlevelencounter!”MedicaldocumentationisnotaboutHOWMUCHyouwrite!ItisaboutWHATyouwrite!第二頁，共三十五頁，編輯于2023年，星期二MedicalTemplates

CanHelp!第三頁，共三十五頁，編輯于2023年，星期二WhatareMedicalTemplates?StandardizedpatientencounterformsusingAdobePDFTechnologyUseasapaperformORCompleteformelectronically第四頁，共三十五頁，編輯于2023年，星期二MedicalTemplatesFeaturesDocumentationpromptersHCFA1997documentationguidelinesQualityremindersMedicarePQRICheckboxesSavetimeSaveenergyFillableTextBoxesEasytouseSavetimeSaveenergyTimesavedisMoneyearned!第五頁，共三十五頁，編輯于2023年，星期二TheNewAmbulatoryEvaluationTemplatefromMedicalTemplatesStillhaseasytousecheckboxesandfillabletextboxes!NowwithnewfeaturesROSwithseparate“yes”and“no”buttonsforeaseofdocumenting“pertinentpositiveandnegative”findings“Reset”buttonforeachsectionofROSBuiltinremindersofdocumentationguidelinesforsectionsofthehistoryandphysicalexamLinkbuttonfor1997GuidelinesforEvaluation&ManagementServices第六頁，共三十五頁，編輯于2023年，星期二DocumentationremindersofrequirementsfortherelevantsectionLinktothe1997GuidelinesforEvaluation&ManagementServicesSeparate“yes”and“no”optionsfordocumentingpertinent

positiveandnegativeresponsesResetbuttons第七頁，共三十五頁，編輯于2023年，星期二ManyPhysiciansUnderCode!Mosthealthcareprovidersdomoreworkthantheirdocumentationsupports!

And,asthesayinggoes,ifitisn’tdocumented,itdidn’thappen!第八頁，共三十五頁，編輯于2023年，星期二HowMuchIsAtStake?Fact

33-52%ofpatientencountersareUNDERcoded

(JABFP2001;14:184-92andFPMOctober2003“Howtogetallthe99214syoudeserve”)DifferencesinMedicarereimbursement99214->99215=$3099214->99213=$30

Ifyousee30patientsperdayyoumaylose$300ormoreperday![33%(30patients/day)x$30/patient=$300/day]Working5days/weekfor50weeks,thatisapotentiallossof$75,000injust1yearduetoinadequatecoding!!!第九頁，共三十五頁，編輯于2023年，星期二WhatIsTheGain?Decreasingbillingandcodingerrorsbyjust50%couldmeananincreaseofnearly

$40,000

peryearinpracticerevenues!

Theequivalentofseeinganadditional690patients/yearOr,anextra3patients/day!WITHOUTTHEEXTRAWORK!第十頁，共三十五頁，編輯于2023年，星期二BenefitsofMedicalTemplatesEasytouseLegibleFastandsimpletocompleteSavesdictationandtranscriptioncostsFastandsimpletoimplementinanypracticeStandardizesdocumentationEnhancesriskmanagementstrategiesReducestheriskofdowncodingWhendocumentationisappropriateforbillingcode????????第十一頁，共三十五頁，編輯于2023年，星期二Professional,MedicalandLegalBenefitsLegible,thorough,andstandardizeddocumentationisaprovenstrategytoreduceriskThoroughdocumentationbecomesthestandardofcareImproved,thoroughdocumentationcansupportAuditsofBillingcodeswhencorrectcodeisbilledforlevelofdocumentationMandatoryQualityreportingPayForPerformanceQualityAssuranceprojectsMaintenanceofCertificationprojectsSelfevaluationofpracticeperformanceABIMPracticeImprovementModule第十二頁，共三十五頁，編輯于2023年，星期二AQuickReviewof

MedicalDocumentation

Requirements第十三頁，共三十五頁，編輯于2023年，星期二PatientEncounters

TheCentersforMedicareandMedicaidServices(CMS)haspublisheddefinitionsanddocumentationguidelinesforthekeycomponentsofamedicalencounternote,usingCPTcodes.第十四頁，共三十五頁，編輯于2023年，星期二KeyComponentsofDocumentationHistoryExamMedicalDecisionMakingCounselingCoordinationofCareNatureofPresentingProblemTime1997GuidelinesforEvaluation&ManagementServices/MLNProducts/Downloads/MASTER1.pdfKeycomponentsinselectingthelevelofE/Mservices第十五頁，共三十五頁，編輯于2023年，星期二TheHistory第十六頁，共三十五頁，編輯于2023年，星期二HistoryComponentsandLevelsHPIROSPFSHTypeofHistoryBriefN/AN/AProblemFocusedBriefProblempertinentN/AExpandedProblemFocusedExtendedExtendedPertinentDetailedExtendedCompleteCompleteComprehensiveNewpatientevaluationsMUSThaveatleastaDetailedHistory第十七頁，共三十五頁，編輯于2023年，星期二HistoryofPresentIllnessEVERYencounterMUSTcontainaChiefComplaint!Preferentiallystatedinpatients’wordsElementsofHPI

Location Quality Severity Duration Timing Context Modifyingfactors AssociatedSignsandSymptomsBriefContains1-3elementslistedExtendedContains34elementsORdiscusses3chronicorinactiveconditions第十八頁，共三十五頁，編輯于2023年，星期二ReviewofSystemsConstitutionalSymptomsEyesEars,Nose,Mouth,ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/ImmunologicProblemPertinentDocumentsresponsestothesystemdirectlyrelatedtothepresentingproblemExtendedDocumentspositiveandnegativeresponsesto2-9systemsrelatedtotheproblemCompleteDocumentsallpositiveandnegativeresponsestosystemsrelatedtothepresentingproblemANDallothersystems(10ormoretotal)第十九頁，共三十五頁，編輯于2023年，星期二Past,FamilyandSocialHistoryPastMedicalHistoryIllnesses,Operations,InjuriesandTreatmentsFamilyMedicalHistoryIncludeheritablediseasesandthosethatplacethepatientatincreasedriskSocialHistoryAnageappropriatereviewofpastandcurrentactivitiesPertinentDocumentatleast1itemfromANYofthe3areasItmustbedirectlyrelatedtotheproblemsidentifiedintheHPIComplete

AllinitialinpatientservicesrequireaCompletePFSHDocumentatleast1itemfromEACHofthe3areas第二十頁，共三十五頁，編輯于2023年，星期二TheExam第二十一頁，共三十五頁，編輯于2023年，星期二RecognizedSingleOrganSystemsCardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkinDetailedAnextendedexamoftheaffectedbodyareaororgans/organsystemandanothersymptomaticorrelatedareaComprehensiveAgeneralmulti-systemexamAcompleteexamofanorgansystemandotherrelatedbodyareasororgansystemsMostlevelsrequireaminimumofaDetailedExam第二十二頁，共三十五頁，編輯于2023年，星期二Multi-organSystemExamDetailed33vitalsignsBP,sittingorstandingBP,supinePulse,rateandregularityRespirationsTemperatureHeightWeight32elements*ofatleast6organsystemsorbodyareasexaminedOR31elementofatleast12organsystemsComprehensive32elements*inatleast9organsystemsorbodyareas*Referto1997GuidelinesforEvaluation&ManagementServices第二十三頁，共三十五頁，編輯于2023年，星期二SingleOrganSystemExamDetailedDocument312elements*(NOTEyeandPsychiatricexams)EyeandPsychexamsdocument39elementsComprehensiveDocumentALLelements**Referto1997GuidelinesforEvaluation&ManagementServices第二十四頁，共三十五頁，編輯于2023年，星期二ElementsofIndividualOrganSystemsConstitutionalVitalsignsGeneralappearanceofpatientNutrition,Bodyhabitus,Development,Deformities,GroomingEyesInspectionofconjunctivaeandlidsExamofpupilsandirisesOphthalmoscopicexamofopticdiscsEars,Nose,MouthandThroatExternalinspectionofearsandnoseOtoscopicexamAssessmentofhearingInspectionofnasalmucosa,septum,andturbinatesInspectionoflips,teethandgumsExamoforopharynxNeckExamofneckThyroidRespiratoryAssessmentofeffortPercussionofchestAuscultationPalpationofchestCardiovascularPalpationofheartAuscultationCarotidarteryexamAbdominalaortaexamFemoralarteriesexamPedalpulsesexamExtremitiesforedemaorvaricosities

Chest(Breasts)InspectionPalpationGastrointestinalAbdominalexamLiverandspleenexamHerniapresenceorabsenceAnus,perineum,rectumexamStoolforoccultblood1997GuidelinesforEvaluation&ManagementServices第二十五頁，共三十五頁，編輯于2023年，星期二Examelements,continuedLymphaticNeckAxillaGroinOtherMusculoskeletalGaitandstationInspection,palpationdigitsandnailsExamofbones,joints,musclesAND1ormoreInspectionorpalpationRangeofmotionandpresence/absenceofpainStabilityMusclestrengthandtoneSkinInspectionPalpationNeurologicCranialnervesDeeptendonreflexesSensationPsychiatricJudgmentandinsightOrientationtoperson,time,placeMemory,recentandremoteMoodandaffectGenitourinaryMaleScrotalcontentsPenisDigitalrectalexamofprostateglandFemaleExternalgenitaliaUrethraBladderexamCervixUterusAdnexa/parametria1997GuidelinesforEvaluation&ManagementServices第二十六頁，共三十五頁，編輯于2023年，星期二MedicalDecisionMaking第二十七頁，共三十五頁，編輯于2023年，星期二ComplexityofMedicalDecisionMakingNumberofDiagnosesOrManagementOptionsAmountand/orComplexityofDatatobeReviewedRiskofComplicationsand/orMorbidityorMortalityComplexityofDecisionMakingMinimalMinimalorNoneMinimalStraightforwardLimitedLimitedLowLowMultipleModerateModerateModerateExtensiveExtensiveHighHigh第二十八頁，共三十五頁，編輯于2023年，星期二Examplesof

Documentation

Requirements第二十九頁，共三十五頁，編輯于2023年，星期二InitialHospitalCareMustmeetallcriteria

99223ComprehensiveHistoryandExamHighcomplexityMedicaldecisionmaking99222ComprehensiveHistoryandExamModeratecomplexityMedicaldecisionmaking99221DetailedORComprehensiveHistoryandExamStraightforwardorLowComplexityMedicaldecisionmaking第三十頁，共三十五頁，編輯于2023年，星期二InitialInpatientConsultationMustmeetallcriteria99255ComprehensiveHistoryANDExamHighcomplexitymedicaldecisionmaking99254ComprehensiveHistoryANDExamModeratecomplexitymedicaldecisionmaking99253DetailedHistoryANDExamLowcomplexitymedicaldecisionmaking第三十一頁，共三十五頁，編輯于2023年，星期二NewOutpatientEncounter

NotaConsultMustmeetallcriteria99205ComprehensiveHistoryandExamHighcomplexitymedicaldecisionmak