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  • Pulmonary Follow Up Evaluation

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    e-MedTools
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    The Pulmonary/Critical Care hospital followup MedicalTemplate is suitable for pulmonologists, critical care physicians, intensivists, hospitalists and other health care providers. When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service, including critical care.

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    Pulmonary Follow up Evaluation

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    The Pulmonary/Critical Care hospital followup MedicalTemplate is suitable for pulmonologists, critical care physicians, intensivists, hospitalists and other health care providers. When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service, including critical care.

    Copyright:

    © All Rights Reserved
    Flag for inappropriate content
    3K views1 page

    Pulmonary Follow Up Evaluation

    Uploaded by

    e-MedTools
    The Pulmonary/Critical Care hospital followup MedicalTemplate is suitable for pulmonologists, critical care physicians, intensivists, hospitalists and other health care providers. When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service, including critical care.

    Copyright:

    © All Rights Reserved
    Flag for inappropriate content
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    Pulmonary Follow Up Evaluation Patient Name Patient DOB MRN

    Date Chief complaint/Reason for consult Referring MD


    Start Time Stop time

    Data Reviewed History of Present Illness


    Allergy list Tobacco use Dyspnea Cough Sputum Hemoptysis Edema Excessive Daytime Sleepiness
    Medication list
    Past Medical History
    Past Surgical History
    Social History
    Family Medical History
    Patient’s Blood Pressure log
    Recent labs and diagnostic tests
    Review of Systems Physical Exam
    ✔
    = Patient denies problems NonInvasive Ventilator (CPAP, BiPAP) Settings
    www.e-medtools.com
    General Alert Vitals T P R BP Sats %
    Constitutional
    Weight changes Fatigue Fever ENT Nasal mucosa Dentition Oropharynx Mallampati I II III IV

    Eyes Neck Normal to palpation Thyroid No JVD


    Vision changes Pain Resp Clear to auscultation
    www.e-medtools.com Dullness to percussion No respiratory distress
    ENT/mouth No chest wall defects Decreased fremitus Bronchial breath sounds
    Ulcers Tooth pain Nose bleeds Absence of intercostal respiratory retractions Egophony (E to A change)
    Resp CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema
    See HPI
    GI No palpable masses Liver and spleen not palpable No hepatojugular reflux
    CV
    Lymph www.e-medtools.com
    No lymphadenopathy
    Chest pain Exercise intolerance
    Diaphoresis Paroxysmal nocturnal dyspnea Musc Tone Gait

    GI Extrem No clubbing No cyanosis


    Nausea Vomiting Diarrhea Skin No rashes, ecchymoses, nodules, ulcers
    Abdominal pain after eating Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Affect
    GU www.e-medtools.com
    Additional Findings
    Dysuria Polyuria Erectile dysfunction
    Musc
    Myalgias Bony pain Claudication Impression & Plan
    Skin/breasts Patient has completed advanced health care directives 47 HCPOA is
    Sores, ulcers Dry, cracked skin www.e-medtools.com
    Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
    Neuro
    Numbness Paresthesias Focal weakness
    Endo
    Hypoglycemia Tremors
    www.e-medtools.com
    Heme/lymph
    Easy bruising Swollen lymph nodes
    Allergy/Immun
    Sinus pain Nasal discharge
    Psych
    Depression Anxiety Hallucinations

    Follow up
    This clinic
    Primary Care
    Ophthalmology
    Cardiology
    Other

    Signature
    cc
    Labs Urinalysis CBC PT, PTT, INR BMP LFTs BNP EKG ECHO TSH CT chest Other
    Therapy Albuterol MDI/Neb Inhaled corticosteroids Oral steroids Long-acting beta agonist Intranasal steroids Other

    ©MB and RR 2006-2008 Revised 10March08 e-medtools.com

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