DSS, Inc. Clinical Note Template Inventory (170)

Transcription

1 DSS, Inc. Clinical Note Template Inventory (170) Last updated: December 31st, 2004 TABLE OF CONTENTS AUDIOLOGY/SPEECH... 2 CARDIOLOGY/PULMONARY... 2 DENTAL... 2 GENERAL... 3 HOME HEALTH... 3 LONG TERM CARE /NURSING HOME... 3 MENTAL HEALTH/SOCIAL WORK... 3 NURSING... 4 NUTRITION (DIETETICS)... 4 PRIMARY CARE... 5 REHABILITATION... 5 SCREENING/EDUCATION... 5 SPECIALTIES... 5 SUBSTANCE ABUSE... 7 SURGICAL/PROCEDURES/ANESTHESIA... 7 INDEX

2 AUDIOLOGY/SPEECH Audiology Progress Note Audiology Assessment ** Audiology Diagnostic Test ** Audiology Exam Note ** Modified Barium Swallow Study Nurse Hearing Screen Speech Pathology Note FORMS\126_AUDI\ FORMS\126_AUDI\ FORMS\126_AUDI\ FORMS\126_AUDI\ FORMS\126_AUDI\ FORMS\112_SURG\ FORMS\126_AUDI\ CARDIOLOGY/PULMONARY Anticoagulation Clinic Note ** Cardiac Rehab Note ** Cardiac Stress Note ** Cerebrovascular Duplex Evaluation ** Holter Tape Cardiac Note ** Myocardial Infarction Thrombolytic Therapy NIH Stroke Scale Assessment Nurse Adenosine Pre-Thallium Stress Test Nurse Cardiac Risk Factor Nurse CPR Record Nursing Cardiac Note ** Pulmonary Function Test Interpretation ** FORMS\119_PHAR\ FORMS\118_NURS\ FORMS\111_MEDI\ FORMS\112_SURG\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\111_MEDI\ DENTAL Examination Oral Examination and Treatment Plan General Dentistry Examination Dental Nursing Home Note Dental History Intake Dental Procedure Note Endodontic Treatment Note Periodontic Examination Note Periodontic Treatment Note Fixed Prosthodontics Note Prosthodontic Implant Note Maxillofacial/Equilibration Note Removable Prosthodontics Note Dental Implant Treatment Note OMFS Post Surgical Note OMFS Pre-Surgical Note OMFS Consultation Note OMFS Admission Note OMFS Inpatient Progress Note Alternative OMFS Clinic Note OMFS Clinic Note Dental Education Note FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\ FORMS\160_DENT\

3 Dental Hygiene Note FORMS\160_DENT\ GENERAL Advance Directive Note Adverse Drug Reaction Note ** Attending Brief Addendum to Resident Note Attending Detailed Addendum to Resident Note Blood Component/Transfusion Order Brain Death Note Clinical Restraint Note ** Comprehensive History and Physical Examination Discharge Plan ** DNR Note ** Graphical Pain Assessment Inpatient Antibiotic Note ** Physician Discharge Note ** Pronouncement of Death Note ** Resident Supervision Note for Attending Restraint Renewal Note Special Transportation Mode Note ** HOME HEALTH Home Based Primary Care Initial Home Health Visit ** FORMS\136_CONS\ FORMS\119_PHAR\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\113_PATH\ FORMS\136_CONS\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\136_CONS\ FORMS\136_CONS\ FORMS\118_NURS\ FORMS\119_PHAR\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\116_MENT\ FORMS\122_SOCI\ FORSM\117_NURS\ FORMS\117_NURS\ LONG TERM CARE /NURSING HOME LTC Rehab Note FORMS\118_NURS\ Nurse LTC Note FORMS\118_NURS\ Nurse LTC Referral Summary FORMS\118_NURS\ Nursing Home Referral ** FORMS\122_SOCI\ Physician s CNH Referral ** FORMS\111_MEDI\ MENTAL HEALTH/SOCIAL WORK Beck Depression Inventory Self-Assessment (BDI) Center for Epidemiologic Studies Depression Scale (CES-D) Day Treatment Note Geropsychology Assessment Initial Outpatient Plan Mental Status Exam ** MH Group Note (national) MH Individual Note (national) MH Medication Management Note (national) MH Prescriber Note (national) FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\

4 MHICM/Psychosocial Assessment & Treatment Plan Nurse Outpatient Substance Abuse Treatment Nurse Seclusion and Restraint Check-Up Outpatient Therapy Note Psychiatric Assessment ** Screen AIMS (Abnormal Involuntary Movement Scale) Screen Barnes Akathasia ** Screen Dyskinesia Monitoring ** Screen Hamilton Depression Screen Mini-Mental Status Exam Screen Quality of Life ** Screen Simpson-Angus ** Screen Yesavage Geriatric Depression Screen Yesavage Geriatric Depression Long Form Screen Zung Self-Rating Depression Social Work Note ** Social Work Post Discharge Follow-up Note ** Suicide Assessment Treatment Plan FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\116_MENT\ FORMS\122_SOCI\ FORMS\122_SOCI\ FORMS\116_MENT\ FORMS\116_MENT\ NURSING Braden Scale Comprehensive Initial Nursing Assessment DAR Intake and Output Discharge Instruction Note Emergency Room Assessment ** Initial Nursing Assessment Part I Initial Nursing Assessment Part II Initial Nursing Assessment Part III Nursing Admission Assessment Nursing Discharge Note Nursing Discharge Summary II Nursing Shift Assessment I Nursing Transfer Summary II PAR Score Scheduled Clinic Visit Note Shift Assessment/Summary Walk-In Disposition Wound Assessment NUTRITION (DIETETICS) Initial Inpatient Nutrition Assessment ** Inpatient Enteral/Parenteral Note ** Nutrition Inpatient Follow-Up ** Nutrition Inpatient Moderate/Severe ** Nutrition Outpatient Follow-Up ** Parenteral Nutritional Note FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\120_NUTR\ FORMS\120_NUTR\ FORMS\120_NUTR\ FORMS\120_NUTR\ FORMS\120_NUTR\ FORMS\119_PHAR\

5 PRIMARY CARE Acute Gout Note ** Diabetic Foot Primary Care History & Physical (95 guidelines) REHABILITATION Nurse Rehabilitation Note ** Physical Therapy Exam Note ** Recreational Therapy Assessment ** Recreational Therapy Note ** Recreational Therapy Plan ** Rehabilitation Brief Note ** SCREENING/EDUCATION Diabetic Education ** Health Promotion Screening Note ** Nurse Health Maint & Disease Prevention) Screen Brief Prv Health/Chronic Disease ** Screen Comprehensive Prev Health/Chronic Disease ** Smoking Cessation Initial Note ** SPECIALTIES Allergy Desensitization Schedule ** Allergy Testing ** GI Nurse Endoscopy Post-Procedure GI Nurse Endoscopy Procedure GI Nurse Pre-Procedure Endoscopy GI Telephone Follow-Up ** Infectious Disease HIV Initial History & Physical ** Infectious Disease HIV Post-Test Counseling Infectious Disease HIV Pre-Test Counseling Neurology EEG Report ** Neurology EMG Report ** Neurology Screen Parkinson Rating Scale ** Nurse Prostate Screen Ophthalmology Optometry Assessment ** Orthopedic Follow-Up ** Orthopedic History Intake ** Pharmacy Discharge Instructions Renal Hemodialysis Treatment ** Renal Nurse Dialysis Plan ** Respiratory Bronchoscopy Respiratory Education Airway Pressure ** Respiratory Sleep Apnea ** Respiratory Therapy Comprehensive ** FORMS\111_MEDI\ FORMS\118_NURS\ FORMS\111_MEDI\ FORMS\117_NURS\ FORMS\117_NURS\ FORMS\117_NURS\ FORMS\117_NURS\ FORMS\117_NURS\ FORMS\117_NURS\ FORMS\118_NURS\ FORMS\111_MEDI\ FORMS\118_NURS\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\119_PHAR\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\118_NURS\ FORMS\112_SURG\ FORMS\112_SURG\ FORMS\112_SURG\ FORMS\119_PHAR\ FORMS\118_NURS\ FORMS\118_NURS\ FORMS\111_MEDI\ FORMS\111_MEDI\ FORMS\116_MENT\ FORMS\111_MEDI\

6 Rheumatology Exam & Minor Procedure Note ** FORMS\117_NURS\

7 SUBSTANCE ABUSE Addictions Treatment Center Note ** Nurse Substance Abuse Admission Screen CIWA Withdrawal ** Substance Abuse Admission FORMS\116_MENT\ FORMS\118_NURS\ FORMS\122_SOCI\ FORMS\116_MENT\ SURGICAL/PROCEDURES/ANESTHESIA Anesthesia Pre/Post Op Assessment ** FORMS\112_SURG\ Informed Consent Note FORMS\116_MENT\ Invasive Procedure Note ** FORMS\112_SURG\ Minor Operative Note ** FORMS\112_SURG\ Nurse Med/Surg Observation FORMS\112_SURG\ Post Op Progress Note ** FORMS\112_SURG\ Special Procedure Note ** FORMS\118_NURS\ Templates followed by a ** may need to be updated to reflect current clinical procedures and documentation standards. If you have suggestions for revamping this template, contact your local CAC/Administrator who can coordinate with the CNT Development Team at DSS, Inc. 7

8 INDEX Acute Gout Note, 5 Addictions Treatment Center Note, 7 Advance Directive Note, 3 Adverse Drug Reaction Note, 3 Allergy Desensitization Schedule, 5 Allergy Testing, 5 Alternative OMFS Clinic Note, 2 Anesthesia Pre/Post Op Assessment, 7 Anticoagulation Clinic Note, 2 Attending Brief Addendum to Resident Note, 3 Attending Detailed Addendum to Resident Note, 3 Audiology Assessment, 2 Audiology Diagnostic Test, 2 Audiology Exam Note, 2 Audiology Progress Note, 2 BDI. See Beck Depression Inventory Self- Assessment Beck Depression Inventory Self-Assessment, 3 Blood Component/Transfusion Order, 3 Braden Scale, 4 Brain Death Note, 3 Cardiac Rehab. Note, 2 Cardiac Stress Note, 2 Center for Epidemiologic Studies Depression Scale, 3, See Center for Epidemiologic Studies Depression Scale Cerebrovascular Duplex Evaluation, 2 Clinical Restraint Note, 3 Comprehensive History and Physical Examination, 3 Comprehensive Initial Nursing Assessment, 4 DAR Intake and Output, 4 Day Treatment Note, 3 Dental Education Note, 3 Dental History Intake, 2 Dental Hygiene Note, 3 Dental Implant Treatment Note, 2 Dental Nursing Home Note, 2 Dental Procedure Note, 2 Diabetic Education, 5 Diabetic Foot, 5 Discharge Instruction Note, 4 Discharge Plan, 3 DNR Note, 3 EEG Report, 5 Emergency Room Assessment, 4 Endodontic Treatment Note, 2 Fixed Prosthodontics Note, 2 General Dentistry Examination, 2 Geropsychology Assessment, 3 GI Nurse Endoscopy Post-Procedure, 5 GI Nurse Endoscopy Procedure, 5 GI Nurse Pre-Procedure Endoscopy, 5 GI Telephone Follow-Up, 5 Graphical Pain Assessment, 3 Health Promotion Screening Note, 5 Holter Tape Cardiac Note, 2 Home Based Primary Care, 3 Infectious Disease HIV Initial History & Physical, 5 Infectious Disease HIV Post-Test Counseling, 5 Infectious Disease HIV Pre-Test Counseling, 5 Informed Consent Note, 7 Initial Home Health Visit, 3 Initial Inpatient Nutrition Assessment, 4 Initial Nursing Assessment Part I, 4 Initial Nursing Assessment Part II, 4 Initial Nursing Assessment Part III, 4 Initial Outpatient Plan, 3 Inpatient Antibiotic Note, 3 Inpatient Enteral/Parenteral Note, 4 Invasive Procedure Note, 7 LTC Rehab Note, 3 Maxillofacial/Equilibration Note, 2 Mental Status Exam, 3 MH Group Note (national), 3 MH Individual Note (national), 4 MH Medication Management Note (national), 4 MH Prescriber Note (national), 4 MHICM/Psychosocial Assessment & Treatment Plan, 4 Minor Operative Note, 7 Myocardial Infarction Thrombolytic Therapy, 2 Neurology EMG Report, 5 Neurology Screen Parkinson Rating Scale (Unified), 5 NIH Stroke Scale Assessment, 2 Nurse Adenosine Pre-Thallium Stress Test, 2 Nurse Cardiac Risk Factor, 2 Nurse CPR Record, 2 Nurse Health Maint & Disease Prevention, 5 Nurse Hearing Screen, 2 Nurse LTC Note, 3 Nurse LTC Referral Summary, 3 Nurse Med/Surge Observation, 7 Nurse Outpatient Substance Abuse Treatment, 4 Nurse Prostate Screen, 5 Nurse Rehabilitation Note, 5 Nurse Seclusion and Restraint Check-Up, 4 Nurse Substance Abuse Admission, 7 Nursing Admission Assessment, 4 Nursing Cardiac Note, 2 Nursing Discharge Note, 4 Nursing Discharge Summary II, 4 Nursing Home Referral, 3 Nursing Shift Assessment I, 4 Nursing Transfer Summary II, 4 Nutrition Inpatient Follow-Up, 4 Nutrition Inpatient Moderate/Severe, 4 Nutrition Outpatient Follow-Up, 5 OMFS Admission Note, 2 OMFS Clinic Note, 3 OMFS Consultation Note, 2 OMFS Inpatient Progress Note, 2 OMFS Post Surgical Note, 2 OMFS Pre-Surgical Note, 2 Ophthalmology Optometry Assessment, 5 Oral Examination and Treatment Plan, 2 8

9 Orthopedic Follow-Up, 5 Orthopedic History Intake, 5 Outpatient Therapy Note, 4 PAR Score, 4 Parenteral Nutritional Note, 5 Periodontic Examination Note, 2 Periodontic Treatment Note, 2 Pharmacy Discharge Instructions, 5 Physical Therapy Exam Note, 5 Physician Discharge Note, 3 Physician s CNH Referral, 3 Post Op Progress Note, 7 Primary Care History & Physical, 5 95 guidelines, 5 Pronouncement of Death Note, 3 Prosthodontic Implant Note, 2 Psychiatric Assessment, 4 Pulmonary Function Test Interpretation, 2 Recreation Therapy Assessment, 5 Recreational Therapy Note, 5 Recreational Therapy Plan, 5 Rehabilitation Brief Note, 5 Removable Prosthodontics Note, 2 Renal Hemodialysis Treatment, 5 Renal Nurse Dialysis Plan, 6 Resident Supervision Note for Attending, 3 Respiratory Bronchoscopy, 6 Respiratory Education Airway Pressure, 6 Respiratory Sleep Apnea, 6 Respiratory Therapy Comprehensive, 6 Restraint Renewal Note, 3 Rheumatology Exam & Minor Procedure Note, 6 Scheduled Clinic Visit Note, 4 Screen AIMS (Abnormal Involuntary Movement Scale), 4 Screen Barnes Akathasia, 4 Screen Brief Prv Health/Chronic Disease, 5 Screen CIWA Withdrawal, 7 Screen Comprehensive Prev Health/Chronic Disease, 5 Screen Dyskinesia Monitoring, 4 Screen Hamilton Depression, 4 Screen Mini-Mental Status Exam, 4 Screen Quality of Life, 4 Screen Simpson-Angus, 4 Screen Yesavage Geriatric Depression, 4 Screen Yesavage Geriatric Depression Long Form, 4 Screen Zung Self-Rating Depression, 4 Shift Assessment/Summary, 4 Smoking Cessation Initial Note, 5 Social Work Note, 4 Social Work Post Discharge Follow-up Note, 4 Special Procedure Note, 7 Special Transportation Mode Note - not soc work, 3 Speech Pathology Note, 2 Substance Abuse Admission, 7 Suicide Assessment, 4 Treatment Plan, 4 Walk-In Disposition, 4 Wound Assessment, 4 9