Documentation Pocket Cards



Examples of Major / Minor Template Cases

MAJOR

1. Head injury with brief LOC 2. Kidney stone

3. Fall and hip pain and unable to walk 4. PID

5. Overdose 6. Cardiac Arrhythmia

7. GI bleed 8. MVA arrive by squad

9. Chest pain 10.Headache with workup

11. CVA 12. Admitted patients

MINOR

Everything Else

(be sure to get 6 bullets on physical exam)

EKG / X-ray Requirements and Examples

EKG: A) Read by who?

B) At least 3 of the following 6 items: rate, rhythm, axis, intervals, comparison, ischemia.

Example: “EKG by my interpretation: normal sinus rhythm, rate of 70, axis normal, no ischemia”

X-Ray: A) Read by who.

B) Part studied.

C) Number of views.

D) Conclusions.

Example: “Chest x-ray, 2 views, by my interpretation: lung fields clear, heart size normal, mediastinum normal.”

Examples of Major / Minor Template Cases

MAJOR

1. Head injury with brief LOC 2. Kidney stone

3. Fall and hip pain and unable to walk 4. PID

5. Overdose 6. Cardiac Arrhythmia

7. GI bleed 8. MVA arrive by squad

9. Chest pain 10.Headache with workup

11. CVA 12. Admitted patients

MINOR

Everything Else

(be sure to get 6 bullets on physical exam)

EKG / X-ray Requirements and Examples

EKG: A) Read by who?

B) At least 3 of the following 6 items: rate, rhythm, axis, intervals, comparison, ischemia.

Example: “EKG by my interpretation: normal sinus rhythm, rate of 70, axis normal, no ischemia”

X-Ray: A) Read by who.

B) Part studied.

C) Number of views.

D) Conclusions.

Example: “Chest x-ray, 2 views, by my interpretation: lung fields clear, heart size normal, mediastinum normal.”

“Group Normal” macros for each exam system/body area:

Constitutional: none

Eyes: conjunctiva without injection, pupils equally round and reactive.

ENT: gross inspection of ears and nose unremarkable, gross auditory acuity intact.

Neck: no masses, no thyromegaly.

Respiratory: good respiratory effort, lungs clear.

Cardiovascular: PMI not displaced, heart regular with no murmur or gallop.

Chest (breasts): none

Abdomen: none

Genitourinary: none

Lymphatic: neck without adenopathy, supraclavicular area without adenopathy.

Musculoskeletal: none

Skin: no significant rash, warm and dry to palpation.

Neurological: cranial nerves II - XII grossly intact, sensory grossly intact.

Psychiatric: oriented to person, place and time; judgment appropriate.

** Be sure to dictate the organ system **

“Group Normal” macros for each exam system/body area:

Constitutional: none

Eyes: conjunctiva without injection, pupils equally round and reactive.

ENT: gross inspection of ears and nose unremarkable, gross auditory acuity intact.

Neck: no masses, no thyromegaly.

Respiratory: good respiratory effort, lungs clear.

Cardiovascular: PMI not displaced, heart regular with no murmur or gallop.

Chest (breasts): none

Abdomen: none

Genitourinary: none

Lymphatic: neck without adenopathy, supraclavicular area without adenopathy.

Musculoskeletal: none

Skin: no significant rash, warm and dry to palpation.

Neurological: cranial nerves II - XII grossly intact, sensory grossly intact.

Psychiatric: oriented to person, place and time; judgment appropriate.

** Be sure to dictate the organ system **

Dictation Template “Minor”

Chief Complaint:

History of Present Illness:

Physical Exam: (be sure to get 6 bullets on physical exam)

Laboratory Results:

Interpretive Services: EKG’s, Pulse Ox and X-Rays interpreted by us.

Emergency Department Course:

Final Diagnosis: Be sure to make it reflect the pt’s acuity.

X-Ray Views

Below are the minimum number of views according to CPT guidelines for each study listed. The number of views must be documented. If the study done was limited, ie. less views - be sure to document this.

4 mandible 3 shoulder 2 hip 1 or 2 CXR

3 facial 2 humerus 3 knee 3 ribs

3 nasal 3 elbow 2 femur 2 sternum

4 orbits 2 forearm 2 tib/fib

3 sinuses 3 wrist 3 ankle 4 C-spine

4 skull 3 hand 3 foot 2 D-spine

2 finger 2 calcaneus 4 L-spine

2 toes 2 Sacrum

Dictation Template “Minor”

Chief Complaint:

History of Present Illness:

Physical Exam: (be sure to get 6 bullets on physical exam)

Laboratory Results:

Interpretive Services: EKG’s, Pulse Ox and X-Rays interpreted by us.

Emergency Department Course:

Final Diagnosis: Be sure to make it reflect the pt’s acuity.

X-Ray Views

Below are the minimum number of views according to CPT guidelines for each study listed. The number of views must be documented. If the study done was limited, ie. less views - be sure to document this.

4 mandible 3 shoulder 2 hip 1 or 2 CXR

3 facial 2 humerus 3 knee 3 ribs

3 nasal 3 elbow 2 femur 2 sternum

4 orbits 2 forearm 2 tib/fib

3 sinuses 3 wrist 3 ankle 4 C-spine

4 skull 3 hand 3 foot 2 D-spine

2 finger 2 calcaneus 4 L-spine

2 toes 2 Sacrum

Dictation Template “Major”

Chief Complaint:

History of Present Illness:

Past Medical History:

Family History:

Social History:

Review of Systems: (may include positives and “all other systems neg”)

Be sure to dictate body area Need at least 10 systems reviewed

1. constitutional 8. musculoskeletal

2. eyes 9. integumentary

3. ENT 10. neurological

4. cardiovascular 11. psychiatric

5. respiratory 12. endocrine

6. gastrointestinal 13. hematological/lymphatic

7. genitourinary 14. allergic / immunologic

Physical Exam: Need at least 9 organ systems with 2 bullets each system

Be sure to dictate body area

1. Constitutional 9. Musculoskeletal

2. Eyes 10. Integumentary

3. ENT 11. Neurologic

4. Neck 12. Psychiatric

5. Cardiovascular 13. Endocrine

6. Respiratory 14. Hematologic / Lymphatic

7. Gastrointestinal 15. Allergic / Immunologic

8. Genitourinary

Laboratory Results:

Interpretive Services: EKG’s, Pulse Ox and X-Rays interpreted by us.

Emergency Department Course: Include Critical Care time here.

Diagnostic Impression: Be sure to make it reflect the pt’s acuity.

Attending Note:

Dec. 6, 1997

Dictation Template “Major”

Chief Complaint:

History of Present Illness:

Past Medical History:

Family History:

Social History:

Review of Systems: (may include positives and “all other systems neg”)

Be sure to dictate body area Need at least 10 systems reviewed

1. constitutional 8. musculoskeletal

2. eyes 9. integumentary

3. ENT 10. neurological

4. cardiovascular 11. psychiatric

5. respiratory 12. endocrine

6. gastrointestinal 13. hematological/lymphatic

7. genitourinary 14. allergic / immunologic

Physical Exam: Need at least 9 organ systems with 2 bullets each system

Be sure to dictate body area

1. Constitutional 9. Musculoskeletal

2. Eyes 10. Integumentary

3. ENT 11. Neurologic

4. Neck 12. Psychiatric

5. Cardiovascular 13. Endocrine

6. Respiratory 14. Hematologic / Lymphatic

7. Gastrointestinal 15. Allergic / Immunologic

8. Genitourinary

Laboratory Results:

Interpretive Services: EKG’s and X-Rays read by us.

Emergency Department Course: Include Critical Care time here.

Diagnostic Impression: Be sure to make sure it reflects the acuity

Attending Note:

Dec. 6, 1997

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