Wiki I need help with e/m level state.

[MsMaddy]

I have a template my doctor has created and wants to know how can we make this a level 4 or what is the highest level we can get on this. Please see below. KEEP IN MIND WE DO HAVE A LITTLE STICKER ON THE SIDE OF THE CHART THAT MA RECORDS THE VITAL SIGNS, WEIGHT.


ACUTE GASTROENTERITIS

___ DAYS TEMP_____


FEVER Y N DEHYDRATION Y N _____%
NAUSEA Y N ABDOMEN TENDER Y N DIFFUSE ___q
VOMITING Y N BOWEL SOUNDS Y N
ANOREXIA Y N PERITONEAL SIGNS Y N
ABDOMINAL PAIN Y N LUNGS CLEAR Y N
CRAMPING Y N ENT CLEAR Y N
DIARRHEA Y N
HEMATEMESIS Y N
HEMATOCHEZIA Y N
RECENT TRAVEL Y N
ANTBX/NSAID USE Y N DURATION_________
MEDS TRIED Y N __________

ENTERITIS GASTRITIS GASTROENTERITIS

STOOL O&P C&S C.DIFICILE OCCULT BLOOD WBC CBC ESR BMP H.PYLORI


ANTIDIARRHEAL OTC RX__________
ANTIEMETIC OTC RX__________
ANTISPASMODIC OTC RX__________

DIET: CLEAR LIQUIDS BRAT DAIRY RESTRICTED REGULAR

FLUIDS ACETAMINOPHEN REST RTW_______


THANKS IN ADVANCE
MSMADDY

 

[LLovett]

Is this the entire note?

All I see are 2 elements of HPI, ___Days, Meds tried
2 ROS, Social history, and a little bit of exam for cons and GI.

The history is stuck at EPF, under 97 exam is PF under 95 EPF, your MDM will vary obviously, but the best I could come up with is a 99213.

Not an ideal template in my opinion at all.

Laura, CPC, CEMC

 

[MsMaddy]

Yes it is the only note. So what else do you recommend should be added on?
This isn't so much of a template, it like one of those sticker doctors use for pt who comes in for URI, BRONCHITIS, PHARYNGITIS.

Thanks
msmaddy

 

[FTessaBartels]

Please see my remarks in Family Practice

Ms Maddy,
I answered a similar question you posted on the Family Practice forum where you asked about a "vaginitis" template.

The same general comments apply here, so please take a look at my response on that other forum.

A template for commonly seen problems CAN be a good way to ensure that you capture all the medically necessary documentation. BUT you need to be sure that you are not just completing boxes to get a higher level, but rather are performing a medically necessary service (and then documenting the service that was performed).

Hope that helps.

F Tessa Bartels, CPC, CEMC