学校舞蹈总结

Broughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsMedicalTemplatesMakingMedicalDocumentationSimpleandPainlesse-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsProblemAfamiliarlament... “NomatterhowmuchIwriteinmyhistoryandphysicalexamnote,Ineverseemtodocumentenoughtosubstantiateahighlevelencounter!”MedicaldocumentationisnotaboutHOWMUCHyouwrite!ItisaboutWHATyouwrite!e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsMedicalTemplatesCanHelp!e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsWhatareMedicalTemplates?StandardizedpatientencounterformsusingAdobePDFTechnologyUseasapaperformORCompleteformelectronicallye-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsMedicalTemplatesFeaturesDocumentationpromptersHCFA1997documentationguidelinesQualityremindersMedicarePQRICheckboxesSavetimeSaveenergyFillableTextBoxesEasytouseSavetimeSaveenergyTimesavedisMoneyearned!e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsTheNewAmbulatoryEvaluationTemplatefromMedicalTemplatesStillhaseasytousecheckboxesandfillabletextboxes!NowwithnewfeaturesROSwithseparate“yes”and“no”buttonsforeaseofdocumenting“pertinentpositiveandnegative”findings“Reset”buttonforeachsectionofROSBuiltinremindersofdocumentationguidelinesforsectionsofthehistoryandphysicalexamLinkbuttonfor1997GuidelinesforEvaluation&ManagementServicese-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsDocumentationremindersofrequirementsfortherelevantsectionLinktothe1997GuidelinesforEvaluation&ManagementServicesSeparate“yes”and“no”optionsfordocumentingpertinentpositiveandnegativeresponsesResetbuttonse-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsManyPhysiciansUnderCode!Mosthealthcareprovidersdomoreworkthantheirdocumentationsupports!And,asthesayinggoes,ifitisn’tdocumented,itdidn’thappen!e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsHowMuchIsAtStake?Fact 33-52%ofpatientencountersareUNDERcoded(JABFP2001;14:184-92andFPMOctober2003“Howtogetallthe99214syoudeserve”)DifferencesinMedicarereimbursement99214->99215=$3099214->99213=$30Ifyousee30patientsperdayyoumaylose$300ormoreperday![33%(30patients/day)x$30/patient=$300/day]Working5days/weekfor50weeks,thatisapotentiallossof$75,000injust1yearduetoinadequatecoding!!!e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsWhatIsTheGain?Decreasingbillingandcodingerrorsbyjust50%couldmeananincreaseofnearly$40,000peryearinpracticerevenues!Theequivalentofseeinganadditional690patients/yearOr,anextra3patients/day!WITHOUTTHEEXTRAWORK!e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsBenefitsofMedicalTemplates Easytouse Legible Fastandsimpletocomplete Savesdictationandtranscriptioncosts Fastandsimpletoimplementinanypractice Standardizesdocumentation Enhancesriskmanagementstrategies ReducestheriskofdowncodingWhendocumentationisappropriateforbillingcodeÖÖÖÖÖÖÖÖe-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsProfessional,MedicalandLegalBenefitsLegible,thorough,andstandardizeddocumentationisaprovenstrategytoreduceriskThoroughdocumentationbecomesthestandardofcareImproved,thoroughdocumentationcansupportAuditsofBillingcodeswhencorrectcodeisbilledforlevelofdocumentationMandatoryQualityreportingPayForPerformanceQualityAssuranceprojectsMaintenanceofCertificationprojectsSelfevaluationofpracticeperformanceABIMPracticeImprovementModulee-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsAQuickReviewofMedicalDocumentationRequirementse-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsPatientEncountersTheCentersforMedicareandMedicaidServices(CMS)haspublisheddefinitionsanddocumentationguidelinesforthekeycomponentsofamedicalencounternote,usingCPTcodes.e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsKeyComponentsofDocumentationHistoryExamMedicalDecisionMakingCounselingCoordinationofCareNatureofPresentingProblemTime1997GuidelinesforEvaluation&ManagementServiceshttp://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdfKeycomponentsinselectingthelevelofE/Mservicese-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsTheHistorye-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsHistoryComponentsandLevelsNewpatientevaluationsMUSThaveatleastaDetailedHistorye-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsHistoryofPresentIllnessEVERYencounterMUSTcontainaChiefComplaint!Preferentiallystatedinpatients’wordsElementsofHPI Location Quality Severity Duration Timing Context Modifyingfactors AssociatedSignsandSymptomsBriefContains1-3elementslistedExtendedContains³4elementsORdiscusses3chronicorinactiveconditionse-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsReviewofSystemsConstitutionalSymptomsEyesEars,Nose,Mouth,ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/ImmunologicProblemPertinentDocumentsresponsestothesystemdirectlyrelatedtothepresentingproblemExtendedDocumentspositiveandnegativeresponsesto2-9systemsrelatedtotheproblemCompleteDocumentsallpositiveandnegativeresponsestosystemsrelatedtothepresentingproblemANDallothersystems(10ormoretotal)e-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsPast,FamilyandSocialHistoryPastMedicalHistoryIllnesses,Operations,InjuriesandTreatmentsFamilyMedicalHistoryIncludeheritablediseasesandthosethatplacethepatientatincreasedriskSocialHistoryAnageappropriatereviewofpastandcurrentactivitiesPertinentDocumentatleast1itemfromANYofthe3areasItmustbedirectlyrelatedtotheproblemsidentifiedintheHPICompleteAllinitialinpatientservicesrequireaCompletePFSHDocumentatleast1itemfromEACHofthe3arease-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsTheExame-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsRecognizedSingleOrganSystemsCardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkinDetailedAnextendedexamoftheaffectedbodyareaororgans/organsystemandanothersymptomaticorrelatedareaComprehensiveAgeneralmulti-systemexamAcompleteexamofanorgansystemandotherrelatedbodyareasororgansystemsMostlevelsrequireaminimumofaDetailedExame-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsMulti-organSystemExamDetailed³3vitalsignsBP,sittingorstandingBP,supinePulse,rateandregularityRespirationsTemperatureHeightWeight³2elements*ofatleast6organsystemsorbodyareasexaminedOR³1elementofatleast12organsystemsComprehensive³2elements*inatleast9organsystemsorbodyareas*Referto1997GuidelinesforEvaluation&ManagementServicese-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsSingleOrganSystemExamDetailedDocument³12elements*(NOTEyeandPsychiatricexams)EyeandPsychexamsdocument³9elementsComprehensiveDocumentALLelements**Referto1997GuidelinesforEvaluation&ManagementServicese-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsElementsofIndividualOrganSystemsConstitutionalVitalsignsGeneralappearanceofpatientNutrition,Bodyhabitus,Development,Deformities,GroomingEyesInspectionofconjunctivaeandlidsExamofpupilsandirisesOphthalmoscopicexamofopticdiscsEars,Nose,MouthandThroatExternalinspectionofearsandnoseOtoscopicexamAssessmentofhearingInspectionofnasalmucosa,septum,andturbinatesInspectionoflips,teethandgumsExamoforopharynxNeckExamofneckThyroidRespiratoryAssessmentofeffortPercussionofchestAuscultationPalpationofchestCardiovascularPalpationofheartAuscultationCarotidarteryexamAbdominalaortaexamFemoralarteriesexamPedalpulsesexamExtremitiesforedemaorvaricositiesChest(Breasts)InspectionPalpationGastrointestinalAbdominalexamLiverandspleenexamHerniapresenceorabsenceAnus,perineum,rectumexamStoolforoccultblood1997GuidelinesforEvaluation&ManagementServicese-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsExamelements,continuedLymphaticNeckAxillaGroinOtherMusculoskeletalGaitandstationInspection,palpationdigitsandnailsExamofbones,joints,musclesAND1ormoreInspectionorpalpationRangeofmotionandpresence/absenceofpainStabilityMusclestrengthandtoneSkinInspectionPalpationNeurologicCranialnervesDeeptendonreflexesSensationPsychiatricJudgmentandinsightOrientationtoperson,time,placeMemory,recentandremoteMoodandaffectGenitourinaryMaleScrotalcontentsPenisDigitalrectalexamofprostateglandFemaleExternalgenitaliaUrethraBladderexamCervixUterusAdnexa/parametria1997GuidelinesforEvaluation&ManagementServicese-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsMedicalDecisionMakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsComplexityofMedicalDecisionMakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsExamplesofDocumentationRequirementse-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsInitialHospitalCareMustmeetallcriteria99223ComprehensiveHistoryandExamHighcomplexityMedicaldecisionmaking99222ComprehensiveHistoryandExamModeratecomplexityMedicaldecisionmaking99221DetailedORComprehensiveHistoryandExamStraightforwardorLowComplexityMedicaldecisionmakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsInitialInpatientConsultationMustmeetallcriteria99255ComprehensiveHistoryANDExamHighcomplexitymedicaldecisionmaking99254ComprehensiveHistoryANDExamModeratecomplexitymedicaldecisionmaking99253DetailedHistoryANDExamLowcomplexitymedicaldecisionmakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsNewOutpatientEncounterNotaConsultMustmeetallcriteria99205ComprehensiveHistoryandExamHighcomplexitymedicaldecisionmaking99204ComprehensiveHistoryandExamModeratecomplexitymedicaldecisionmaking99203DetailedHistoryandExamLowcomplexitymedicaldecisionmakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsNewOutpatientConsultMustmeetallcriteria99245ComprehensiveHistoryComprehensiveExamHighcomplexitymedicaldecisionmaking99244ComprehensiveHistoryComprehensiveExamModeratecomplexitymedicaldecisionmaking99243DetailedHistoryDetailedExamLowcomplexitymedicaldecisionmakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsEstablishedOutpatientEncounterMustmeet2outof3criteria99215ComprehensiveHistoryComprehensiveExamHighcomplexitymedicaldecisionmaking99214DetailedHistoryDetailedExamModeratecomplexitymedicaldecisionmaking99213ExpandedProblemFocusedHistoryExpandedProblemFocusedExamLowcomplexitymedicaldecisionmakinge-MedtoolsPhysiciandesignedmedicaldocumentationtoolsBroughttoyoubye-MedtoolsandMedicalTemplatesPhysiciandesignedmedicaldocumentationtoolsWehopeyoufoundthispresentationhelpful!Wearegratefultoallthepatientandknowledgeablebillingandcodingspecialistswehaveencounteredalongtheway!Wewelcomeyourcommentsatwww.e-medtools.come-MedtoolsPhysiciandesignedmedicaldocumentationtools