Templates and Shortcuts - Voice to Docs



TCO Gatto Templates and Shortcuts

For Review of Reports dictations

• Dates should be written out in full.  There should be a comma after the date (July, 1, 2015,) if the date is in the middle of the sentence.

• Each x-ray, mri, and doctor's visit should be it's own paragraph - not a bunch of them together in one paragraph.

• Each X-Ray, MRI, Dr. visit(says “I reviewed a progress note”, or office visit should have all that info in one paragraph – history, exam,tests reviewed, impression, and plan.  Then start a new paragraph for the next visit or report. 

• A report without an office visit, goes in a separate paragraph by itself.

• Time spent at the end goes in its own paragraph

• Spacing between sentences needs to be consistent – either one or two.

• Numerals should be spelled out instead of using numbers.

• The department in a hospital should be capitalized even if there is no hospital affiliated.  (Emergency Room, Pain Management, etc)

• The doctor sometimes  switches back and forth between present and past tense in the same paragraph.  This should be corrected when typing to all be in the past tense since it is a dictation about a past visit.

• After completing the report, it should be put in the system as Finish Later.

General Notes

• Dr. Gatto works with PA’s Ries(used to be Gibson) & Dispensa.

• They will often ask for 2 parts of a note to be combined(part done by Dr. Gatto & part by a PA). When you receive a partial report by Dr. Gatto and he says “xx will be dictating the rest…”, or the partial report from the PA:

o First check on the Worklist or EHR to see if there is anything else for that date yet. If there is, pull up the report from the worklist & paste the new dictation part into the correct paragraphs of the report.

o If you are typing the first half of the job, use “finish later” to complete the report. This way when the second half is dictated, this can be pulled up & the new dictation added here.

• Dr. Gatto does IME reports, sometimes together with the PA. Vanessa Dispensa will dictate a Review of Reports for the patient before the patient comes in. These should be typed in the IME template, before the patient comes in, as the doctor will review that before/while he sees the patient. After the visit, Dr. Gatto will dictate the rest of the IME that will be added to the ROR that’s already in the system.

• Dr. Gatto’s notes are typed using Intergy Transcription Writer(see ‘Using Intergy.doc’ for details)

• For patients who had xrays taken in the office a second x-ray report should be created (see ‘Using Intergy.doc’ for more info.)

• Patient information(Name, ID#, WC/MVA info, etc.) should be looked up in the EHR (see ‘TCO EHR Use Instructions.doc’ for details)

• Dr. Gatto and PA’s has very specific templates & wants those to be followed at all times. He also has some lines in the template that are supposed to be there always, even when not dictated. Specifically:

o FU: at end of opening: "His/Her review of systems is otherwise unchanged from the prior visit."

o FU: at end of opening, before PE: Past Medical/Surgical/Medication/Allergy/Social & Family History: Reviewed and otherwise unchanged from the prior visit.

o Chief Complaint, New Patient or New Problem at the end of HPI: Review of systems: on chart.

o Social History At the end of social history, put in "Family History: on chart.". This isn’t dictated, but they want it in there.

o IME: The top and the last two paragraphs are always in an IME.

o Discussion/plan was instructed on how to take the medications safely. If there is any change in or worsening of symptoms, which we went over at length today, then we will hear from immediately. understands the above. * This should only go in if the patient has medications.

o In SG’s Studies section: “These will be reviewed with Dr. Gatto.” This shold go in even if the patient was not seen with Dr. Gatto.

• The only sections that can be excluded from the template would be:

o Antecedent History (except for an IME or WC or MVA note - where they are required).

o Occupational history.

o Studies (unless x-rays were obtained that day and they just forgot to dictate them).

o Review of Reports (only mandatory in an IME).

o Work Status is ONLY REQUIRED in WC notes.

• Second page letterhead should look like this. It should be put in automatically, but if it’s not, you can create an autocorrect for it & update manually.

(2 blank lines)

«Patient_Full_Name» «Appt_Date»

2

(2 blank lines)

• If there is a short addendum to a very long report, the addendum should be saved itself without the full report for billing/payroll. The following paragraph can be added at the top of the addendum report to be saved:

o Addendum: This is an addendum that was added to a previous report via Vitera Intergy Transcription Writer. The complete report was uploaded to the Intergy system and will be found in the EHR(Electronic Health Record) system.

Tips

• “end of dictation” does not always mean end of dictation. Sometimes the dictation continues.

• A very short dictation(0:17) will often be an addendum. If you check the short ones before starting, it will save time later in these cases.

• Chief Complaint and HPI: The HPI starts where they talk about whatever is bothering the patient in the office now or the most recent issue.

• Patient on blood thinners – blood thinner name should be CAPS and bold. Blood thinner list:

o Plavix

o Aggrenox

o Coumadin

o Pradaxa

o Brilinta

o Xarelto

o Effient

o Eliquis

• In the Studies Section, if x-rays were obtained in the office that day(This should be checked up in their system), they want the reading of the x-rays to start with "We have obtained x-rays today." This way there is no question as to when they were done. If x-rays are obtained but they are not dictated on then it is considered a partial dictation.

• In MRI sections

o The axial images show

o the sagittal images show

o displacing the forming right S1 nerve root

• If there are no studies dictated or obtained in that office visit then leave out the Studies Section.

• When Dr. Gatto dictates an Addendum and says to put it in bold, he wants the entire addendum bolded, not just the heading, so that it will definitely get his attention.

• In the Review of Reports: He likes every report to be listed separately and not combined into a paragraph.

• When they refer to a level and degree of spondylolisthesis, I always do it as "Grade I" "Grade II" Grade I to II" , etc. The reason for this is that there can be so many numbers and levels listed in studies that it helps differentiate between the listhesis areas and the areas and levels of stenosis or herniations.

• When he dictates "5-1" or "4-5", it is very important to put what spinal level it is because sometimes, he will do that when he discusses the neck and the lower back and then everything gets confused.  Even if not dictated, it should be transcribed "L5-S1" or "C4-5" or whatever.

• Physical Exam: They will use the normals listed below. Anything dictated as abnormal must be entirely in Bold.

(Ex: She has no skin lesions in her thoracic or lumbar spine. Normal alignment. No atrophy. There is no pain to palpation. She has good motion in her back with some mild subjective pain to range of motion, especially to back extension. No instability. Good motion in both hips without pain. Negative Faber bilaterally.)

• Medications: List meds. Only need dosage schedule for Opiods/Narcotics/Neurontin/Lyrica

• Allergy: If there are no allergies they want it to read: No known drug allergies.   If there are allergies to medications they want the names in CAPS. (not in bold)

• IME Template: The individual who is being evaluated is never referred to as “patient” unless it is part of a direct quote. Insert his or her name even if dictated as patient. What I found helpful was that at the end of an IME I do a quick search for the word patient and correct where necessary.

• They frequently mix together Social History and Occupational History: They have to be separated for IMEs, WCs, and MVAs. With regular patients I separate them if the occupational history is more than just a short line. The general physician should be included in the Social History.

• In Assessment and Causality, when he says same as or copy from the note from 05/12/2015 they need to copy and paste the actual information from the older note, not transcribe "same as May 12, 2015 note".

• In the Assessment, there should be a space between each number in the list

• In Assessment and Discussion and Plan: Please put a comma in between "medicine" and "therapy".

• In the medications and past surgical history there should be a period and not a comma between the procedures and medications. Ex:

Past Surgical History:  Status post prior lumbar laminectomy L4-5 by Dr. Schoeb in 2010. She has done well from that.  Stent placement in 2012 and 2013.  Lithotripsy left kidney.  She had a ganglion cyst removal from her left wrist.

Medications:  Bystolic.  PLAVIX.  Pravachol. 

• Dr. Gibson often dictates not in full sentences. This should be corrected to full sentences.

• If VD dictates in her report that Sarah was consulted, at the end of the dictation just add something say ‘this case was discussed with Sarah Ries’

•

Common Phrases (edit based on positive findings):

• HPI(usually): He has no specific weakness. There has been no change in bowel or bladder function, balance or coordination, or fine motor skills. There is no numbness or tingling to his anus or genitalia.

• History: He overall feels 90% improved as compared to....."

• When this is given as “none”, “normal” or “negative”:

Antecedent History: He denies any prior Worker’s Compensation injuries. He denies any prior motor vehicle accidents. He denies any prior similar symptoms, studies, treatments or chiropractic care for these.

He will just say “he denies” and then put the whole line above.

Then edit by putting any prior WC injuries in first and then add "She denies any other prior Worker’s Compensation injuries." The same applies to prior MVAs. And then also to prior treatments, studies etc.

(Ex: As an example I transcribed this section for this patient as: Antecedent History: She denies any prior Worker’s Compensation injuries. She had a prior motor vehicle accident in 2005 where she states that she “hurt all over”, particularly having neck pain and particularly right knee symptoms and injury. She was eventually treated with surgery for the right knee for arthroscopic surgery for the meniscus. She denies any other prior motor vehicle accidents. She did do chiropractic care about twenty years ago but she is unsure of who it was. She denies any other prior similar symptoms, studies, treatments or chiropractic care for these. On further questioning she does recall having a little bit of upper and lower back pain years ago when she was working at McDonald’s. )

If he dictates an antecedent history for patient, but it is not a WC, you should still put in the line about denying any prior WC injuries etc.

• Chief Complaint: This is the first time that I am meeting this __ year old _______ who presents here today in consultation through his Worker’s Compensation physician. He/she has complaints that he/she relates began with an injury at work.

• Past Medical History: When diabetes, they will always dictate either "insulin dependent diabetes" or "non-insulin dependent diabetes". This is an important distinction as it can influence certain treatment decisions.

• Allergy: If they say None or Negative then "No known drug allergies" is what they want.

• “X-rays showed no instability." Will not always have the date of the x-ray.

• Follow up Instructions: They will dictate: “if any worsening of symptoms they will return earlier” (or something to that effect): “If there is any change in or worsening of his symptoms prior to that, which we went over at length today, then we will hear from him immediately. He understands the above.” OR if they dictate worsening, especially cauda equina syndrome, then: “If there is any change in or worsening of his symptoms, especially the signs and symptoms of cauda equina syndrome, which we went over at length today, then we will hear from him immediately. He understands the above.”

• Discussion and Plan add in it if they refer to the "including the signs and symptoms of cauda equina".

• For all three, CAG, SG and VD: Towards the end of the HPI after they have been describing symptoms they will all dictate something about weakness, bowel and bladder control and balance and coordination: What they want transcribed is "No weakness. There has been no change in bowel or bladder function, balance or coordination, or fine motor skills."

• RE: Section, always put the patient's DOB and his Tri County Acct # at the end of whatever he dictates.

• XRay - "No motion on the flexion and extension views."

• Discussion and Plan: At this point in time the patient and I had a talk about HIS/HER problem. We talked about the typical course and progression of the disease as well as the typical treatment and diagnostic options and the risks and benefits between them. ***** Of note: This paragraph is sometimes used in Dr. Gatto’s follow up notes and he will start the D&P with it. It is also sometimes used by Sarah Ries, PA-C and Vanessa Dispensa, PA-C

• In Discussion and Plan will use “... will continue on the exercises that he/she learned at physical therapy on his/her own at home.

• In D&P 1for range of motion, strengthening and conditioning

• Studies: We obtained x-rays today........... "They show the hardware and graft to be in good position. There has been interval progression of the posterolateral fusion." ........................... These will be reviewed with Dr. Gatto.

• Departments should be capitalized (ex: Emergency Room)

• Whenever he recommends a steroid injection, the injection risks template should be inserted into the template.

Common Words:

figure of four testing

Radiculitis

radiculopathy

Peripheral neuritis

peripheral neuropathy

myopathy

myelopathy

myeloradiculopathy

FABER

lateral recess stenosis

give way weakness

cervicothoracic lumbar strain and spasm

up-to-date MRI

osteophytic spurring

formal physical therapy

laminotomy, foraminotomy and decompression

Common Doctor Names

Dr. Naseef

Dr. Schoeb

Dr. Lipp

Dr. Aboody

Harding Radiology

Cedar Knolls

Dr. Gibbens

Dr. Colizza

Templates

FOR W/C AND MVA DICTATIONS:

Add to the top of the note(just under the pt name & account lines):

WC:

EMPLOYER: CLAIM#:

MVA:

INSURANCE CO: CLAIM#:

Add to bottom of the note: Work Status: With regards to work, (WC notes MUST have this, but MVAs do not require this).

Causality: From a causality standpoint, ------------There are times when he will insert a Causality section. This is put above the Discussion and Plan section.

NORMAL PHYSICAL EXAM TEMPLATES FOR CAG & SG

On physical examination today, the examinee is a xx-year-old man/woman of normal development and body habitus (or whatever s/he is). Awake, alert and oriented times 3 and of normal mood and affect. R (or L) hand dominant. 5’9” tall and weighs 213 pounds.  BP is 138/78 with Pulse of 83.

 

Cervical Spine shows normal alignment, no atrophy, no skin lesions or scars. Normal range of motion in the cervical region without pain or exacerbation of neurological symptoms. There is no pain to palpation. Negative Spurling’s. Negative Lhermitte’s.

Shoulders show normal symmetric motion bilaterally without pain.  There are no signs of rotator cuff tendinitis, instability or apprehension. 

Thoracic Spine shows normal alignment, no atrophy, no skin lesions or scars. Normal range of motion in the thoracic region without pain or exacerbation of neurological symptoms. No pain to palpation.

Lumbar Spine shows normal alignment, no atrophy, no skin lesions or scars. Normal range of motion in the lumbar region without pain or exacerbation of neurological symptoms. There is no pain to palpation.

Hips show normal symmetric motion bilaterally without pain.  Sacro-iliac joints show no pain to palpation and FABER test is negative bilaterally.

Extremities show normal symmetric range of motion of the joints bilaterally without pain. Normal stability. No pain to palpation. No swelling or edema with normal capillary refill. No worrisome skin lesions.

Neurologically, the upper and lower extremities are intact to motor strength and light touch sensation with symmetric reflexes.  There is no atrophy.  Negative seated or standing straight leg raise and a negative contralateral straight leg raise.  Negative Babinski.  Negative clonus.  Negative Hoffmann’s.  Negative Romberg’s.  Normal gait. Normal coordination.  Patient is able to walk on heels and toes well with full strength, good balance and stability.

Normal cervical: has no skin lesions in cervical spine. Normal alignment. No atrophy. There is no pain to palpation. has good motion in neck without exacerbation of symptoms. There is no pain to range of motion. No instability.

Normal shoulder: Good motion in both shoulders without exacerbation of pain. No signs of rotator cuff tendinitis, instability or apprehension.

Normal lumbar/thoracolumbar: has no skin lesions in thoracic or lumbar spine. Normal alignment. No atrophy. There is no pain to palpation. has good motion in back without exacerbation of symptoms and there is no pain to range of motion. No instability.

Normal hips: Good motion in both hips without pain. Negative Faber bilaterally.

Normal upper extremity: Neurologically upper extremities appear intact to motor strength and light touch sensation with symmetric reflexes. has no pain to palpation of the extremities. has good range of motion of joints without pain and without instability. The extremities show no swelling or edema and are warm with normal capillary refill and without palpable lymph nodes. There is no atrophy. There are no worrisome skin lesions. Negative Babinski. Negative clonus. Negative Hoffmann’s. Negative Romberg’s. has a normal gait and normal coordination. is able to walk on heels and toes well with good balance and stability.

Normal lower extremity: Neurologically lower extremities appear intact to motor strength and light touch sensation with symmetric reflexes. has no pain to palpation of the extremities. has good range of motion of his joints without pain and without instability. The extremities show no swelling or edema and are warm with normal capillary refill and without palpable lymph nodes. There is no atrophy. There are no worrisome skin lesions. Negative seated or standing straight leg raise and a negative contralateral straight leg raise. Negative Babinski. Negative clonus. has a normal gait and has normal coordination. is able to walk on heels and toes well with good balance and stability.

Normal upper and lower extremities: Neurologically upper and lower extremities appear intact to motor strength and light touch sensation with symmetric reflexes. has no pain to palpation of the extremities. has good range of motion of joints without pain and without instability. The extremities show no swelling or edema and are warm with normal capillary refill and without palpable lymph nodes. There is no atrophy. There are no worrisome skin lesions. Negative seated or standing straight leg raise and a negative contralateral straight leg raise. Negative Babinski. Negative clonus. Negative Hoffmann’s. Negative Romberg’s. has a normal gait and normal coordination. is able to walk on heels and toes well with good balance and stability.

OTHER NORMALS

Cervical spine/stenosis precautions

We also talked about cervical stenosis and the fact that is at increased risk for spinal cord injury including paralysis if were to have an injury to head or neck, even without a fracture. I recommend that do no activities that put head or neck at undue risk. understands the above.

Injection risks:

We talked about the typical injection today, the peri-injection course and the risks including infection, bleeding, nerve damage, dural tears, CSF leak and spinal anesthesia. understands the above.

Surgical risks:

For non-fusion surgery: We talked about the typical surgery today and the typical peri-surgical course as well as the risks. understands the above.

For cervical spine fusion surgery: We talked about the typical surgery today and the typical peri-surgical course as well as the risks. The patient will require a cervical hard molded orthotic brace post-operatively for augmentation of the stabilization post fusion surgery. We will get this patient measured and set up for this brace through our office. understands the above.

For lumbar spine fusion surgery: We talked about the typical surgery today and the typical peri-surgical course as well as the risks. The patient will require a lumbar hard custom molded orthotic brace post-operatively for augmentation of the stabilization post fusion surgery. We will get this patient measured and set up for this brace through our office. understands the above.

Injection Templates

Procedure Note:

Diagnosis: Left shoulder rotator cuff tendinitis.

Procedure: Left shoulder subacromial injection.

The procedure was explained at length to the patient. All questions were answered and the risks and benefits were discussed. The patient understands and would like to go forward with the procedure, which was performed with _________ in the room for assistance. The skin area over the area of greatest pain to palpation was then cleansed with Betadine and draped in the usual sterile fashion. The skin and subcutaneous tissues were anesthetized with several ccs of 1% lidocaine. A 22 gauge spinal needle was placed through the skin down to the left shoulder subacromial bursa.

We injected a mixture of 40 mg of Depo-Medrol, 2 ccs of 1% lidocaine and 2 ccs of 0.25% Marcaine. There were no complications and the patient tolerated the procedure well. Band-aids were placed on the injection sites. The patient was given post injection instructions and was discharged to home.

Procedure Note:

Diagnosis: Right hip trochanteric bursitis.

Procedure: Right hip trochanteric bursal injection.

The procedure was explained at length to the patient. All questions were answered and the risks and benefits were discussed. The patient understands and would like to go forward with the procedure, which was performed with ________ in the room for assistance. The skin area over the area of greatest pain to palpation was then cleansed with Betadine and draped in the usual sterile fashion. The skin and subcutaneous tissues were anesthetized with several ccs of 1% lidocaine. A 22 gauge spinal needle was placed through the skin down to the right trochanteric bursa down to the periosteum of the bone.

We injected a mixture of 40 mg of Depo-Medrol, 2 ccs of 1% lidocaine and 2 ccs of 0.25% Marcaine, peppering the periosteum and the bursa in the area. There were no complications and the patient tolerated the procedure well. Band-aids were placed on the injection sites. The patient was given post injection instructions and was discharged to home.

IME/Narrative Summary Template

He may dictate “put in whatever we use for a Narrative Summary/IME”. These are the paragraphs that he is referring to. The only editing that I do is for the IME paragraphs because it uses the term “today”. When he sometimes does an Addendum to an IME or reviews further reports, then I remove today from the paragraph.

Narrative Summary:

The above opinions are mine and are made to within a reasonable degree of medical probability. They are based upon the reports and studies that were provided to me in the office as well as my direct interviews, evaluations and examinations of the patient in my office.

Thank you for allowing me to participate in the care of your patient. If I can be of any further help in the evaluation or care of the patient, please feel free to call me in my office or to have the patient schedule a follow up visit and evaluation with my office.

IME:

The above opinions are mine and are made to within a reasonable degree of medical probability. They are based upon the reports and studies that were provided to me in the office today as well as my direct interview, evaluation and examination of in my office today.

Thank you for allowing me to participate in the care of . If I can be of any further help in the evaluation or care of , please feel free to call me in my office or to have the patient schedule a follow up visit and evaluation with my office.

Application of Brace:

The patient was fit with a brace today. The brace was adjusted specifically for this patient. They were instructed how to apply the brace, when to wear it and for approximately how long daily. The patient practiced taking it on and off. The patient fully understands the function of the brace is to immobilize initially and then restore mobility. The patient will return to the office at the next scheduled appointment.

Application of Bone Stim:

The external DJO bone growth stimulator was applied to the patient and the patient was instructed to use the stimulator 30 minutes everyday for the next 6 months or until the fusion/nonunion is healed. The stimulator provides increased vascularity to the area which it is placed and increases your body's own natural healing process. There have been hundreds of studies over the last 40 years proving combined magnetic fields and pulsed electromagnetic field in regards to healing fusions. Pulsed electromagnetic fields and Combined Magnetic Fields (CMF) increases osteoblast and osteoclast activity thus creating the optimal environment for bone growth.

The patient is clear on the purpose, function and instructions associated with the stimulator and will follow up in my office.

Signatures

Dr. Charles Gatto / Sarah Ries PA-C / Vanessa Dispensa, PA-C

1. Any Dr. Gatto Office Dictation when he dictates himself or if VanessaDispensa dictates for him:

Sincerely,

 

 

CHARLES A. GATTO, M.D.

Board-Certified, Fellowship-Trained Spine Surgeon

Chief of the Spine Section, Department of Orthopedic Surgery 

Morristown Medical Center of the Atlantic Health System 

Former: Assistant Professor / Chief of Spine Service, Department of Orthopedics 

Mt. Sinai School of Medicine / Mt Sinai Medical Center

 

CAG/

Document electronically signed

2. Sarah Ries, PA-C

The seen for and reviewed with line, should only be included when she dictates that the patient was seen with Dr. Gatto.

SARAH RIES, PA-C; seen for and reviewed with:

CHARLES A. GATTO, M.D.

Board-Certified, Fellowship-Trained Spine Surgeon

Chief of the Spine Section, Department of Orthopedic Surgery 

Morristown Medical Center of the Atlantic Health System 

Former: Assistant Professor / Chief of Spine Service, Department of Orthopedics 

Mt. Sinai School of Medicine / Mt Sinai Medical Center

SG/__

Document electronically signed

Different Situations for Ries Signature:

* Pts on Sara’s schedule should have her signature and be uploaded to her

* When acting as a scribe should be Gatto's signature and my name under the bottom "scribed by ..." Should be uploaded to Gatto. Add CAG/ before the SG/mt in the signature(ex: CAG/SG/mt)

* If Sarah sees the patient and sais "in conjunction with" or "pt was seen w Dr. Gatto etc", put Sarah’s signature (not with seen for and reviewed with) and upload to Sarah.

* IfSsarah see the patient and doesn't say "in conjunction with" even if it’s on Dr. Gatto’s schedule then it should have Sarah’s signature

* If she dictates "seen for and reviewed..." then put that line in.

3. Vanessa Dispensa, PA-C when she sees a patient without Dr. Gatto:

Vanessa Dispensa, PA-C; seen for and reviewed with:

CHARLES A. GATTO, M.D.

Board-Certified, Fellowship-Trained Spine Surgeon

Chief of the Spine Section, Department of Orthopedic Surgery 

Morristown Medical Center of the Atlantic Health System 

Former: Assistant Professor / Chief of Spine Service, Department of Orthopedics 

Mt. Sinai School of Medicine / Mt Sinai Medical Center

 CAG/VD/__

Document electronically signed

Other template to be used when specified:

Patient: Smith, John DOB: DOE: 07/26/2018

Account: Ref Doctor:

OFFICE NOTE

This is the first time that I am meeting this 54-year-old gentleman who presents here today in consultation through his Workers’ Compensation physician at Sedgwick Insurance Company. He reports a work related injury of January 1, 2019. He has complains that he relates began with the reported work event of January 1, 2019, which include acute onset of neck pain and low back pain with onset of right upper extremity radicular symptoms beginning three days later and right lower extremity radicular symptoms beginning one month later. He presents here today for evaluation.

Chief Complaint:

History of Present Illness:

Past Medical History:

Antecedent History: prior Workers’ Compensation injuries. prior motor vehicle accidents. prior similar symptoms, studies, treatments or chiropractic care for the neck, upper back, lower back, or bilateral arm or leg symptoms.

Past Surgical History:

Medications:

ALLERGIES:

Social History: smoking history, drinking history, and pertinent family history .

Primary Care Physician:

Occupational History:

Physical Examination: On physical examination today, the patient is an otherwise healthy-appearing, 54-year-old gentleman of normal development and body habitus or overweightness or obesity. The patient is awake, alert and oriented times 3 and of normal mood and affect with vital signs recorded on the chart. He is 6’ tall and weighs 240 pounds. His blood pressure is 150/90 with a pulse of 80. He is wearing an LSO brace.

He has no skin lesions in his cervical spine. Normal alignment. No atrophy. There is no pain to palpation. He has good motion in his neck without exacerbation of his symptoms. There is no pain to range of motion. No instability. Good motion in both shoulders without exacerbation of pain. No signs of rotator cuff tendinitis, instability or apprehension.

He has no skin lesions in his thoracic or lumbar spine. Normal alignment. No atrophy. There is no pain to palpation. He has good motion in his back without exacerbation of his symptoms and there is no pain to range of motion. No instability. Good motion in both hips without pain. Negative Faber bilaterally.

Neurologically upper extremities appear intact to motor strength and light touch sensation with symmetric reflexes. has no pain to palpation of the extremities. has good range of motion of joints without pain and without instability. The extremities show no swelling or edema and are warm with normal capillary refill and without palpable lymph nodes. There is no atrophy. There are no worrisome skin lesions. Negative Babinski. Negative clonus. Negative Hoffmann’s. Negative Romberg’s. has a normal gait and normal coordination. is able to walk on heels and toes well with good balance and stability.

Neurologically, his lower extremities appear intact to motor strength and light touch sensation with symmetric reflexes. He has no pain to palpation of the extremities. He has good range of motion of his joints without pain and without instability. The extremities show no swelling or edema and are warm with normal capillary refill and without palpable lymph nodes. There is no atrophy. There are no worrisome skin lesions. Negative seated or standing straight leg raise and a negative contralateral straight leg raise. Negative Babinski. Negative clonus. He has a normal gait and has normal coordination. He is able to walk on his heels and his toes well with good balance and stability.

Neurologically, his upper and lower extremities appear intact to motor strength and light touch sensation with symmetric reflexes. He has no pain to palpation of the extremities. He has good range of motion of his joints without pain and without instability. The extremities show no swelling or edema and are warm with normal capillary refill and without palpable lymph nodes. There is no atrophy. There are no worrisome skin lesions. Negative seated or standing straight leg raise and a negative contralateral straight leg raise. Negative Babinski. Negative clonus. Negative Hoffmann’s. Negative Romberg’s. He has a normal gait and normal coordination. He is able to walk on his heels and his toes well with good balance and stability.

Studies:

Assessment:

Discussion and Plan:

We also talked about cervical stenosis and the fact that is at increased risk for spinal cord injury including paralysis if were to have an injury to head or neck, even without a fracture. I recommend that do no activities that put head or neck at undue risk. understands the above.

We talked about the typical injection today, the peri-injection course and the risks including infection, bleeding, nerve damage, dural tears, CSF leak and spinal anesthesia. understands the above.

We talked about the typical surgery today and the typical peri-surgical course as well as the risks. understands the above.

was instructed on how to take the medications safely. If there is any change in or worsening of symptoms, which we went over at length today, then we will hear from immediately. understands the above.

The risks associated with the drugs prescribed by the physician at ASC, including the risks of addiction and overdose were discussed with the patient and/or their surrogate, as were available alternative treatments and the reasons why the prescriptions are necessary for their care. The prescriptions are deemed necessary and appropriate and to not present an un-due risk of abuse, addiction or diversion. See the initial and subsequent physician office visit notes for the patient’s full medical history, results of the physical examinations, the diagnoses, and the treatment plans. Relevant information from the Prescription Monitoring Program was consulted.

Sincerely,

 

 

CHARLES A. GATTO, M.D.

Board-Certified, Fellowship-Trained Spine Surgeon

Chief of the Spine Section, Department of Orthopedic Surgery 

Morristown Medical Center of the Atlantic Health System 

Former: Assistant Professor / Chief of Spine Service, Department of Orthopedics 

Mt. Sinai School of Medicine / Mt Sinai Medical Center

 

CAG/

Document electronically signed

IME SAMPLE format updated January 2020:

IME Dictation Template/Sample(format updated January 2020):

August 23, 2019

 

TO:     …………………., Esq.

           …………………., Attorneys at Law

            1313 Mockingbird Lane, Suite 406B

            Mount Laurel, NJ 08054-5016 

 

RE:      Examinee’s Full Name

DOB: xx-yy-1962

Claim #: 

Atty File #: 

Other types of Claim# etc…

Date of Reported Event: January 12, 2018

Other headings as guided by the Cover Letter.

INDEPENDENT MEDICAL EVALUATION

Dear Mr./Ms. Atty:

 

The following is an Independent Medical Evaluation on Herman Munster.  I met this 57-year-old male/female for the first time today when s/he presented for his independent medical evaluation.   The information recorded below is as per Mr./Ms Munster.

History: Mr./Ms. Munster has complaints that s/he relates began with an event at work on January 12, 2018.  S/He reports that…

Currently: At present Mr./Ms. Smith has complaints of …

Antecedent History: 

Past Medical History: 

Past Surgical History: 

Medications: List meds. Only need dosage schedule for Opiods/Narcotics/Neurontin/Lyrica

Allergies: regarding Meds and pertinent other allergies (not in bold)

Social History: Tobacco / EtOH / Other Drugs /

Occupational History:  10-year history beginning with most current

Physicians: Primary Physician is

Others:

Physical Examination:  

On physical examination today, the examinee is a xx-year-old man/woman of normal development and body habitus (or whatever s/he is). Awake, alert and oriented times 3 and of normal mood and affect. R (or L) hand dominant. x’x” tall and weighs xxx pounds.  BP is xxx/yy with Pulse of xx.

 

Cervical Spine shows normal alignment, no atrophy, no skin lesions or scars. Normal range of motion in the cervical region without pain or exacerbation of neurological symptoms. There is no pain to palpation. Negative Spurling’s. Negative Lhermitte’s.

Shoulders show normal symmetric motion bilaterally without pain.  There are no signs of rotator cuff tendinitis, instability or apprehension. 

Thoracic Spine shows normal alignment, no atrophy, no skin lesions or scars. Normal range of motion in the thoracic region without pain or exacerbation of neurological symptoms. No pain to palpation.

Lumbar Spine shows normal alignment, no atrophy, no skin lesions or scars. Normal range of motion in the lumbar region without pain or exacerbation of neurological symptoms. There is no pain to palpation.

Hips show normal symmetric motion bilaterally without pain. 

Sacro-iliac joints show no pain to palpation and FABER test is negative bilaterally.

Extremities show normal symmetric range of motion of the joints bilaterally without pain. Normal stability. No pain to palpation. No swelling or edema with normal capillary refill. No worrisome skin lesions.

Neurologically, the upper and lower extremities are intact to motor strength and light touch sensation with symmetric reflexes.  There is no atrophy.  Negative seated or standing straight leg raise and a negative contralateral straight leg raise.  Negative Babinski.  Negative clonus.  Negative Hoffmann’s.  Negative Romberg’s.  Normal gait. Normal coordination.  Pt is able to walk on heels and toes well with full strength, good balance and stability.

Studies Reviewed Directly by Dr. Gatto:

MRI Cervical Spine from NJIN dated 2-23-19 shows…

X-Rays of the Lumbar Spine dated 1-5-19 show…

Review of Medical Records and Reports:

Pre-Event Reports:

Multiple notes from primary care physician Dr. Blank were reviewed from 6-2-15 through 12-10-18:

Post Event Reports:

Emergency room notes from MMC dated 1-30-19 state…

Orthopedic notes from Garden State Ortho Dr Jones state…

Assessment:  

- Pre-existing degenerative changes of the … not related to the work event of …

- Acute Lumbar contusion … which appears causally related to the work event of …

- Acute Cervical disc herniation causing right C6 radiculitis

- Etc…

Causality:

The above diagnoses and symptoms…

Impression and Discussion: 

Work and Activity Status:

The above opinions are mine and are made to within a reasonable degree of medical probability.  They are based upon the reports and studies that were provided to me, as well as direct interview, evaluation and examination of Mr/Ms Full Name in my office today. 

If I can be of any further help in his/her evaluation or care, please feel free to call me or schedule a follow evaluation with my office.

 

Sincerely,

 

 

Sincerely,

 

 

CHARLES A. GATTO, M.D.

Board-Certified, Fellowship-Trained Spine Surgeon

Chief of the Spine Section, Department of Orthopedic Surgery 

Morristown Medical Center of the Atlantic Health System 

Former: Assistant Professor / Chief of Spine Service, Department of Orthopedics 

Mt. Sinai School of Medicine / Mt Sinai Medical Center

 

CAG/

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