Monday, February 8, 2010

MedicalTemplates' Outpatient Pulmonary Clinic Evaluation

The folks at e-medtools who create MedicalTemplates have updated their Outpatient Pulmonary Clinic Evaluation for new patient evaluations. This new template looks much better than the previous version! It also appears to have quite a few more convenient features!

The ROS (Review of Systems) has been updated to reflect the ROS on their other templates. Having a ROS with space to document both "yes" and "no" responses makes a great deal of sense medically and legally! The PMH (Past Medical History) is much cleaner, more straightforward, and limited to the most common diagnoses. They have left room, though, for addition of a tailored set of diagnoses, such as specific pulmonary diseases that are not very common. There is also a very nice list of common surgeries that really save on documentation time and effort! Prompters for significant Social History information like ADLs (Activities of Daily Living) and behavioral and occupational risk factors are extraordinarily important to most patients seen by a pulmonologist, but are often excluded from standard medical templates.

The exam is quite extensive with relevant negative and positive findings that, again, stand to save pulmonologists a great deal of time and effort. Time is money, and quality of life is extremely important!

There is significantly more space in the Impression and Plan section, which is a great improvement over the previous version. Space for adequate discussion of the differential diagnoses and treatment options was previously limited.

MedicalTemplates is doing a great job! Documentation of the patient encounter is complex and confusing! There are so many rules that differ with each payor, and often change from year to year, that it makes sense to take a more consistent approach to documenting every patient encounter!

Pulmonary Clinic History and Physical