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History and Physical Medical Office Template - Excel by vtd78719

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History and Physical Medical Office Template document sample

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									                                      READ Workshop Individual Feedback Tally


Name, PGY level, Office Visit note reviewed on 7/1/2009

The following contains all the written feedback given by your colleagues when your note was reviewed at
the READ Workshop. Refer to the "Feedback Form" for explanations of what the numbers mean.


I. Basic Elements
The following basic elements are present:
    Date                                                                        1   1   1   1   1   1   1   1
    Time                                                                        1   1   1   1   1   1   1   1
    Chief complaint or Reason for visit                                         1   1   1   1   1   1   1   1
    Signature                                                                   1   1   1   1   1   1   1   1

II. Subjective
The history portion of the note contains
    a complete and directed HPI based on the chief complaint.                   3   2   2   2   2   2   2   1
    a list of agenda items (e.g., patient & provider concerns).                 3   2   2   2   2   2   2   1
    a discussion of relevant chronic medical conditions.                        2   2   2   2   2   2   2   1
    an updated list of medications.                                             1   1   1   1   1   1   1   1

III. Objective
The physical exam contains documentation of
    a blood pressure.                                                           1   1   1   1   1   1   1   1
    a weight.                                                                   3   3   3   3   3   3   3   3
    a body-mass index (BMI).                                                    3   3   3   3   3   3   3   3
    a description of patient’s general appearance.                              1   1   1   1   1   1   1   1
    findings (positive or negative) pertinent to history elements.              2   2   2   2   2   2   2   2

IV. Data
The note contains updated information on
    recent laboratory data (or documentation that none exists).                 3   3   3   3   3   3   3   3
    diagnostic studies performed at that visit (e.g., U/A, EKG).                3   3   3   3   3   3   3   3
                                       READ Workshop Individual Feedback Tally


V. Assessment & Plan
The assessment and plan section includes
    a summary statement.                                                         3   2   2   2   2   2   1   2
    mention of a differential diagnosis (if appropriate).                        3   2   2   2   2   2   1   2
    a complete list of problems addressed.                                       1   2   2   2   2   2   2   2
    mention of all issues brought up in HPI section.                             1   2   2   2   2   2   2   2
    a specific management plan for each problem listed.                          1   2   2   2   2   2   2   2
    an explanation of rational behind management decisions.                      3   2   2   2   2   2   2   1
    changes made to medication regimen.                                          1   1   1   1   1   1   1   1
    documentation that potential medication side effects discussed.              3   3   3   3   3   3   3   3
    discussion of issues related to general health maintenance.                  1   2   2   2   2   2   2   2
    an agenda for future visits.                                                 1   1   1   1   1   1   1   1
    specific time frame for follow-up (e.g., “follow-up in 3 months”).           1   1   1   1   1   1   3   1
    a plan that is appropriate based on information presented.                   2   2   2   2   2   2   2   1

VI. Billing & Coding
The diagnosis codes are correct based on the content of the note.                3   3   3   2   1   2   1   2
The billing codes are correct based on the content of the note.                  3   1   3   2   2   2   1   2

VII. Overall
This is an effective note.                                                       2   2   2   3   3   2   2   3
More detail is needed in this note.                                              3   2   1   4   3   3   2   2
Too much detail is provided in this note.                                        3   4   5   3   4   5   3   3
The length of this note is appropriate for the complexity of the visit.          1   2   3   2   3   2   3   2
If I didn’t know this patient, this note would help me care for him/her.         2   2   2   1   2   2   2   2


VIII. Comments
Follow up for what?
Too many abbreviations.
No mention of HTN, HPL in Past Medical History.
Discussion of asthma?
Pneumovax?
Is initial med list pre- or post- visit? Not clear.
Is 90-180 really "good glycemic control"?
No billing for D stick.
Is patient up to date on diabetic eye exam? Foot exam?
Lispro SS mentioned in Plan but not on med list.
Microalb?
Advair "PRN"? Not on med list.

								
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