Template for Group Therapy Notes - PDF

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					            DSS, Inc. Clinical Note Template Inventory (170)
Last updated: December 31st, 2004



TABLE OF CONTENTS
AUDIOLOGY/SPEECH ................................................................................................................................ 2
CARDIOLOGY/PULMONARY ................................................................................................................... 2
DENTAL ........................................................................................................................................................ 2
GENERAL ..................................................................................................................................................... 3
HOME HEALTH ........................................................................................................................................... 3
LONG TERM CARE /NURSING HOME..................................................................................................... 3
MENTAL HEALTH/SOCIAL WORK.......................................................................................................... 3
NURSING ...................................................................................................................................................... 4
NUTRITION (DIETETICS)........................................................................................................................... 4
PRIMARY CARE .......................................................................................................................................... 5
REHABILITATION....................................................................................................................................... 5
SCREENING/EDUCATION ......................................................................................................................... 5
SPECIALTIES ............................................................................................................................................... 5
SUBSTANCE ABUSE................................................................................................................................... 7
SURGICAL/PROCEDURES/ANESTHESIA ............................................................................................... 7
INDEX ........................................................................................................................................................... 8




                                                                                                                                                                 1
AUDIOLOGY/SPEECH
                        TITLE                         LOCATION
Audiology Progress Note                      FORMS\126_AUDI\04126001
Audiology Assessment **                      FORMS\126_AUDI\95126002
Audiology Diagnostic Test **                 FORMS\126_AUDI\01126002
Audiology Exam Note **                       FORMS\126_AUDI\95126001
Modified Barium Swallow Study                FORMS\126_AUDI\04126002
Nurse Hearing Screen                         FORMS\112_SURG\96112002
Speech Pathology Note                        FORMS\126_AUDI\97126001



CARDIOLOGY/PULMONARY
                        TITLE                         LOCATION
Anticoagulation Clinic Note **               FORMS\119_PHAR\96119002
Cardiac Rehab Note **                        FORMS\118_NURS\95118013
Cardiac Stress Note **                       FORMS\111_MEDI\95111020
Cerebrovascular Duplex Evaluation **         FORMS\112_SURG\95112008
Holter Tape Cardiac Note **                  FORMS\111_MEDI\97111002
Myocardial Infarction Thrombolytic Therapy   FORMS\111_MEDI\97111003
NIH Stroke Scale Assessment                  FORMS\111_MEDI\02111001
Nurse Adenosine Pre-Thallium Stress Test     FORMS\118_NURS\97118003
Nurse Cardiac Risk Factor                    FORMS\118_NURS\96118005
Nurse CPR Record                             FORMS\118_NURS\95118011
Nursing Cardiac Note **                      FORMS\118_NURS\96118004
Pulmonary Function Test Interpretation **    FORMS\111_MEDI\95111018



DENTAL
                        TITLE                         LOCATION
Examination                                  FORMS\160_DENT\04160001
Oral Examination and Treatment Plan          FORMS\160_DENT\95160014
General Dentistry Examination                FORMS\160_DENT\95160003
Dental Nursing Home Note                     FORMS\160_DENT\95160004
Dental History Intake                        FORMS\160_DENT\95160001
Dental Procedure Note                        FORMS\160_DENT\04160002
Endodontic Treatment Note                    FORMS\160_DENT\95160002
Periodontic Examination Note                 FORMS\160_DENT\95160009
Periodontic Treatment Note                   FORMS\160_DENT\95160005
Fixed Prosthodontics Note                    FORMS\160_DENT\95160010
Prosthodontic Implant Note                   FORMS\160_DENT\95160011
Maxillofacial/Equilibration Note             FORMS\160_DENT\95160012
Removable Prosthodontics Note                FORMS\160_DENT\95160013
Dental Implant Treatment Note                FORMS\160_DENT\95160007
OMFS Post Surgical Note                      FORMS\160_DENT\95160015
OMFS Pre-Surgical Note                       FORMS\160_DENT\95160006
OMFS Consultation Note                       FORMS\160_DENT\95160016
OMFS Admission Note                          FORMS\160_DENT\95160017
OMFS Inpatient Progress Note                 FORMS\160_DENT\95160018
Alternative OMFS Clinic Note                 FORMS\160_DENT\95160008
OMFS Clinic Note                             FORMS\160_DENT\95160019
Dental Education Note                        FORMS\160_DENT\95160020
                                                                       2
Dental Hygiene Note                                 FORMS\160_DENT\96160001



GENERAL
                          TITLE                              LOCATION
Advance Directive Note                              FORMS\136_CONS\95136015
Adverse Drug Reaction Note **                       FORMS\119_PHAR\95119001
Attending Brief Addendum to Resident Note           FORMS\111_MEDI\03111002
Attending Detailed Addendum to Resident Note        FORMS\111_MEDI\03111001
Blood Component/Transfusion Order                   FORMS\113_PATH\95113006
Brain Death Note                                    FORMS\136_CONS\95136016
Clinical Restraint Note **                          FORMS\111_MEDI\95111008
Comprehensive History and Physical Examination      FORMS\111_MEDI\95111001
Discharge Plan **                                   FORMS\136_CONS\95136036
DNR Note **                                         FORMS\136_CONS\96136003
Graphical Pain Assessment                           FORMS\118_NURS\03118007
Inpatient Antibiotic Note **                        FORMS\119_PHAR\95119002
Physician Discharge Note **                         FORMS\111_MEDI\97111004
Pronouncement of Death Note **                      FORMS\111_MEDI\95111024
Resident Supervision Note for Attending             FORMS\111_MEDI\03111003
Restraint Renewal Note                              FORMS\116_MENT\95116006
Special Transportation Mode Note **                 FORMS\122_SOCI\96122003



HOME HEALTH
                          TITLE                              LOCATION
Home Based Primary Care                             FORSM\117_NURS\04117001
Initial Home Health Visit **                        FORMS\117_NURS\01117003



LONG TERM CARE /NURSING HOME
                          TITLE                              LOCATION
LTC Rehab Note                                      FORMS\118_NURS\97118001
Nurse LTC Note                                      FORMS\118_NURS\95118014
Nurse LTC Referral Summary                          FORMS\118_NURS\97118010
Nursing Home Referral **                            FORMS\122_SOCI\95122007
Physician’s CNH Referral **                         FORMS\111_MEDI\97111005



MENTAL HEALTH/SOCIAL WORK
                          TITLE                              LOCATION
Beck Depression Inventory Self-Assessment (BDI)     FORMS\116_MENT\03116001
Center for Epidemiologic Studies Depression Scale   FORMS\116_MENT\03116002
(CES-D)
Day Treatment Note                                  FORMS\116_MENT\96116001
Geropsychology Assessment                           FORMS\116_MENT\95116004
Initial Outpatient Plan                             FORMS\116_MENT\98116001
Mental Status Exam **                               FORMS\116_MENT\95116009
MH Group Note (national)                            FORMS\116_MENT\03116005
MH Individual Note (national)                       FORMS\116_MENT\03116006
MH Medication Management Note (national)            FORMS\116_MENT\03116008
MH Prescriber Note (national)                       FORMS\116_MENT\03116007

                                                                              3
MHICM/Psychosocial Assessment & Treatment Plan      FORMS\116_MENT\04116001
Nurse Outpatient Substance Abuse Treatment          FORMS\116_MENT\04116002
Nurse Seclusion and Restraint Check-Up              FORMS\116_MENT\95116007
Outpatient Therapy Note                             FORMS\116_MENT\95116008
Psychiatric Assessment **                           FORMS\116_MENT\97116001
Screen AIMS (Abnormal Involuntary Movement Scale)   FORMS\116_MENT\95116002
Screen Barnes Akathasia **                          FORMS\116_MENT\02116001
Screen Dyskinesia Monitoring **                     FORMS\116_MENT\02116002
Screen Hamilton Depression                          FORMS\116_MENT\03116003
Screen Mini-Mental Status Exam                      FORMS\116_MENT\95116003
Screen Quality of Life **                           FORMS\116_MENT\02116003
Screen Simpson-Angus **                             FORMS\116_MENT\02116004
Screen Yesavage Geriatric Depression                FORMS\116_MENT\03116009
Screen Yesavage Geriatric Depression Long Form      FORMS\116_MENT\04116003
Screen Zung Self-Rating Depression                  FORMS\116_MENT\03116004
Social Work Note **                                 FORMS\122_SOCI\95122003
Social Work Post Discharge Follow-up Note **        FORMS\122_SOCI\95122005
Suicide Assessment                                  FORMS\116_MENT\97116002
Treatment Plan                                      FORMS\116_MENT\01116001



NURSING
                          TITLE                              LOCATION
Braden Scale                                        FORMS\118_NURS\03118004
Comprehensive Initial Nursing Assessment            FORMS\118_NURS\04118005
DAR Intake and Output                               FORMS\118_NURS\04118004
Discharge Instruction Note                          FORMS\118_NURS\97118009
Emergency Room Assessment **                        FORMS\118_NURS\00118002
Initial Nursing Assessment Part I                   FORMS\118_NURS\03118001
Initial Nursing Assessment Part II                  FORMS\118_NURS\03118002
Initial Nursing Assessment Part III                 FORMS\118_NURS\03118003
Nursing Admission Assessment                        FORMS\118_NURS\04118007
Nursing Discharge Note                              FORMS\118_NURS\03118006
Nursing Discharge Summary II                        FORMS\118_NURS\04118001
Nursing Shift Assessment I                          FORMS\118_NURS\04118002
Nursing Transfer Summary II                         FORMS\118_NURS\04118003
PAR Score                                           FORMS\118_NURS\96118007
Scheduled Clinic Visit Note                         FORMS\118_NURS\97118004
Shift Assessment/Summary                            FORMS\118_NURS\95118012
Walk-In Disposition                                 FORMS\118_NURS\00118001
Wound Assessment                                    FORMS\118_NURS\04118006



NUTRITION (DIETETICS)
                          TITLE                              LOCATION
Initial Inpatient Nutrition Assessment **           FORMS\120_NUTR\95120006
Inpatient Enteral/Parenteral Note **                FORMS\120_NUTR\95120005
Nutrition Inpatient Follow-Up **                    FORMS\120_NUTR\95120003
Nutrition Inpatient Moderate/Severe **              FORMS\120_NUTR\95120004
Nutrition Outpatient Follow-Up **                   FORMS\120_NUTR\95120002
Parenteral Nutritional Note                         FORMS\119_PHAR\95119003



                                                                              4
PRIMARY CARE
                          TITLE                                 LOCATION
Acute Gout Note **                                     FORMS\111_MEDI\98111006
Diabetic Foot                                          FORMS\118_NURS\97118002
Primary Care History & Physical (95 guidelines)        FORMS\111_MEDI\03111006



REHABILITATION
                          TITLE                                 LOCATION
Nurse Rehabilitation Note **                           FORMS\117_NURS\01117001
Physical Therapy Exam Note **                          FORMS\117_NURS\97117001
Recreational Therapy Assessment **                     FORMS\117_NURS\02117001
Recreational Therapy Note **                           FORMS\117_NURS\01117002
Recreational Therapy Plan **                           FORMS\117_NURS\95117002
Rehabilitation Brief Note **                           FORMS\117_NURS\98117001



SCREENING/EDUCATION
                          TITLE                                 LOCATION
Diabetic Education **                                  FORMS\118_NURS\95118016
Health Promotion Screening Note **                     FORMS\111_MEDI\98111005
Nurse Health Maint & Disease Prevention)               FORMS\118_NURS\03118005
Screen Brief Prv Health/Chronic Disease **             FORMS\111_MEDI\00111001
Screen Comprehensive Prev Health/Chronic Disease **    FORMS\111_MEDI\00111002
Smoking Cessation Initial Note **                      FORMS\119_PHAR\96119001



SPECIALTIES
                          TITLE                                 LOCATION
Allergy Desensitization Schedule **                    FORMS\111_MEDI\97111008
Allergy Testing **                                     FORMS\111_MEDI\96111013
GI Nurse Endoscopy Post-Procedure                      FORMS\118_NURS\97118008
GI Nurse Endoscopy Procedure                           FORMS\118_NURS\97118007
GI Nurse Pre-Procedure Endoscopy                       FORMS\118_NURS\97118006
GI Telephone Follow-Up **                              FORMS\111_MEDI\95111022
Infectious Disease HIV Initial History & Physical **   FORMS\111_MEDI\01111003
Infectious Disease HIV Post-Test Counseling            FORMS\111_MEDI\95111003
Infectious Disease HIV Pre-Test Counseling             FORMS\111_MEDI\95111002
Neurology EEG Report **                                FORMS\111_MEDI\95111021
Neurology EMG Report **                                FORMS\111_MEDI\96111004
Neurology Screen Parkinson Rating Scale **             FORMS\111_MEDI\02111002
Nurse Prostate Screen                                  FORMS\118_NURS\00118003
Ophthalmology Optometry Assessment **                  FORMS\112_SURG\95112007
Orthopedic Follow-Up **                                FORMS\112_SURG\97112002
Orthopedic History Intake **                           FORMS\112_SURG\97112003
Pharmacy Discharge Instructions                        FORMS\119_PHAR\97119001
Renal Hemodialysis Treatment **                        FORMS\118_NURS\01118003
Renal Nurse Dialysis Plan **                           FORMS\118_NURS\95118010
Respiratory Bronchoscopy                               FORMS\111_MEDI\04111001
Respiratory Education Airway Pressure **               FORMS\111_MEDI\96111012
Respiratory Sleep Apnea **                             FORMS\116_MENT\02116005
Respiratory Therapy Comprehensive **                   FORMS\111_MEDI\95111005
                                                                                 5
Rheumatology Exam & Minor Procedure Note **   FORMS\117_NURS\95117004




                                                                        6
SUBSTANCE ABUSE
                         TITLE                                          LOCATION
Addictions Treatment Center Note **                       FORMS\116_MENT\98116002
Nurse Substance Abuse Admission                           FORMS\118_NURS\01118001
Screen CIWA Withdrawal **                                 FORMS\122_SOCI\95122008
Substance Abuse Admission                                 FORMS\116_MENT\97116003



SURGICAL/PROCEDURES/ANESTHESIA
                         TITLE                                          LOCATION
Anesthesia Pre/Post Op Assessment **                      FORMS\112_SURG\95112006
Informed Consent Note                                     FORMS\116_MENT\96116003
Invasive Procedure Note **                                FORMS\112_SURG\95112002
Minor Operative Note **                                   FORMS\112_SURG\95112003
Nurse Med/Surg Observation                                FORMS\112_SURG\04112001
Post Op Progress Note **                                  FORMS\112_SURG\01112001
Special Procedure Note **                                 FORMS\118_NURS\96118006



Templates followed by a ** may need to be updated to reflect current clinical procedures and
documentation standards. If you have suggestions for revamping this template, contact your
local CAC/Administrator who can coordinate with the CNT Development Team at DSS, Inc.




                                                                                               7
INDEX
Acute Gout Note, 5                                  Infectious Disease HIV Initial History & Physical,
Addictions Treatment Center Note, 7                    5
Advance Directive Note, 3                           Infectious Disease HIV Post-Test Counseling, 5
Adverse Drug Reaction Note, 3                       Infectious Disease HIV Pre-Test Counseling, 5
Allergy Desensitization Schedule, 5                 Informed Consent Note, 7
Allergy Testing, 5                                  Initial Home Health Visit, 3
Alternative OMFS Clinic Note, 2                     Initial Inpatient Nutrition Assessment, 4
Anesthesia Pre/Post Op Assessment, 7                Initial Nursing Assessment Part I, 4
Anticoagulation Clinic Note, 2                      Initial Nursing Assessment Part II, 4
Attending Brief Addendum to Resident Note, 3        Initial Nursing Assessment Part III, 4
Attending Detailed Addendum to Resident Note,       Initial Outpatient Plan, 3
   3                                                Inpatient Antibiotic Note, 3
Audiology Assessment, 2                             Inpatient Enteral/Parenteral Note, 4
Audiology Diagnostic Test, 2                        Invasive Procedure Note, 7
Audiology Exam Note, 2                              LTC Rehab Note, 3
Audiology Progress Note, 2                          Maxillofacial/Equilibration Note, 2
BDI. See Beck Depression Inventory Self-            Mental Status Exam, 3
   Assessment                                       MH Group Note (national), 3
Beck Depression Inventory Self-Assessment, 3        MH Individual Note (national), 4
Blood Component/Transfusion Order, 3                MH Medication Management Note (national), 4
Braden Scale, 4                                     MH Prescriber Note (national), 4
Brain Death Note, 3                                 MHICM/Psychosocial Assessment & Treatment
Cardiac Rehab. Note, 2                                 Plan, 4
Cardiac Stress Note, 2                              Minor Operative Note, 7
Center for Epidemiologic Studies Depression         Myocardial Infarction Thrombolytic Therapy, 2
   Scale, 3, See Center for Epidemiologic Studies   Neurology EMG Report, 5
   Depression Scale                                 Neurology Screen Parkinson Rating Scale
Cerebrovascular Duplex Evaluation, 2                   (Unified), 5
Clinical Restraint Note, 3                          NIH Stroke Scale Assessment, 2
Comprehensive History and Physical                  Nurse Adenosine Pre-Thallium Stress Test, 2
   Examination, 3                                   Nurse Cardiac Risk Factor, 2
Comprehensive Initial Nursing Assessment, 4         Nurse CPR Record, 2
DAR Intake and Output, 4                            Nurse Health Maint & Disease Prevention, 5
Day Treatment Note, 3                               Nurse Hearing Screen, 2
Dental Education Note, 3                            Nurse LTC Note, 3
Dental History Intake, 2                            Nurse LTC Referral Summary, 3
Dental Hygiene Note, 3                              Nurse Med/Surge Observation, 7
Dental Implant Treatment Note, 2                    Nurse Outpatient Substance Abuse Treatment, 4
Dental Nursing Home Note, 2                         Nurse Prostate Screen, 5
Dental Procedure Note, 2                            Nurse Rehabilitation Note, 5
Diabetic Education, 5                               Nurse Seclusion and Restraint Check-Up, 4
Diabetic Foot, 5                                    Nurse Substance Abuse Admission, 7
Discharge Instruction Note, 4                       Nursing Admission Assessment, 4
Discharge Plan, 3                                   Nursing Cardiac Note, 2
DNR Note, 3                                         Nursing Discharge Note, 4
EEG Report, 5                                       Nursing Discharge Summary II, 4
Emergency Room Assessment, 4                        Nursing Home Referral, 3
Endodontic Treatment Note, 2                        Nursing Shift Assessment I, 4
Fixed Prosthodontics Note, 2                        Nursing Transfer Summary II, 4
General Dentistry Examination, 2                    Nutrition Inpatient Follow-Up, 4
Geropsychology Assessment, 3                        Nutrition Inpatient Moderate/Severe, 4
GI Nurse Endoscopy Post-Procedure, 5                Nutrition Outpatient Follow-Up, 5
GI Nurse Endoscopy Procedure, 5                     OMFS Admission Note, 2
GI Nurse Pre-Procedure Endoscopy, 5                 OMFS Clinic Note, 3
GI Telephone Follow-Up, 5                           OMFS Consultation Note, 2
Graphical Pain Assessment, 3                        OMFS Inpatient Progress Note, 2
Health Promotion Screening Note, 5                  OMFS Post Surgical Note, 2
Holter Tape Cardiac Note, 2                         OMFS Pre-Surgical Note, 2
Home Based Primary Care, 3                          Ophthalmology Optometry Assessment, 5
                                                    Oral Examination and Treatment Plan, 2

                                                                                                     8
Orthopedic Follow-Up, 5                      Rheumatology Exam & Minor Procedure Note, 6
Orthopedic History Intake, 5                 Scheduled Clinic Visit Note, 4
Outpatient Therapy Note, 4                   Screen AIMS (Abnormal Involuntary Movement
PAR Score, 4                                   Scale), 4
Parenteral Nutritional Note, 5               Screen Barnes Akathasia, 4
Periodontic Examination Note, 2              Screen Brief Prv Health/Chronic Disease, 5
Periodontic Treatment Note, 2                Screen CIWA Withdrawal, 7
Pharmacy Discharge Instructions, 5           Screen Comprehensive Prev Health/Chronic
Physical Therapy Exam Note, 5                  Disease, 5
Physician Discharge Note, 3                  Screen Dyskinesia Monitoring, 4
Physician’s CNH Referral, 3                  Screen Hamilton Depression, 4
Post Op Progress Note, 7                     Screen Mini-Mental Status Exam, 4
Primary Care History & Physical, 5           Screen Quality of Life, 4
   95 guidelines, 5                          Screen Simpson-Angus, 4
Pronouncement of Death Note, 3               Screen Yesavage Geriatric Depression, 4
Prosthodontic Implant Note, 2                Screen Yesavage Geriatric Depression Long
Psychiatric Assessment, 4                      Form, 4
Pulmonary Function Test Interpretation, 2    Screen Zung Self-Rating Depression, 4
Recreation Therapy Assessment, 5             Shift Assessment/Summary, 4
Recreational Therapy Note, 5                 Smoking Cessation Initial Note, 5
Recreational Therapy Plan, 5                 Social Work Note, 4
Rehabilitation Brief Note, 5                 Social Work Post Discharge Follow-up Note, 4
Removable Prosthodontics Note, 2             Special Procedure Note, 7
Renal Hemodialysis Treatment, 5              Special Transportation Mode Note - not soc work,
Renal Nurse Dialysis Plan, 6                   3
Resident Supervision Note for Attending, 3   Speech Pathology Note, 2
Respiratory Bronchoscopy, 6                  Substance Abuse Admission, 7
Respiratory Education Airway Pressure, 6     Suicide Assessment, 4
Respiratory Sleep Apnea, 6                   Treatment Plan, 4
Respiratory Therapy Comprehensive, 6         Walk-In Disposition, 4
Restraint Renewal Note, 3                    Wound Assessment, 4




                                                                                           9

				
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Description: Template for Group Therapy Notes document sample