DSS, Inc. Clinical Note Template Inventory (170)

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... 8 1

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\04126001 FORMS\126_AUDI\95126002 FORMS\126_AUDI\01126002 FORMS\126_AUDI\95126001 FORMS\126_AUDI\04126002 FORMS\112_SURG\96112002 FORMS\126_AUDI\97126001 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\96119002 FORMS\118_NURS\95118013 FORMS\111_MEDI\95111020 FORMS\112_SURG\95112008 FORMS\111_MEDI\97111002 FORMS\111_MEDI\97111003 FORMS\111_MEDI\02111001 FORMS\118_NURS\97118003 FORMS\118_NURS\96118005 FORMS\118_NURS\95118011 FORMS\118_NURS\96118004 FORMS\111_MEDI\95111018 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\04160001 FORMS\160_DENT\95160014 FORMS\160_DENT\95160003 FORMS\160_DENT\95160004 FORMS\160_DENT\95160001 FORMS\160_DENT\04160002 FORMS\160_DENT\95160002 FORMS\160_DENT\95160009 FORMS\160_DENT\95160005 FORMS\160_DENT\95160010 FORMS\160_DENT\95160011 FORMS\160_DENT\95160012 FORMS\160_DENT\95160013 FORMS\160_DENT\95160007 FORMS\160_DENT\95160015 FORMS\160_DENT\95160006 FORMS\160_DENT\95160016 FORMS\160_DENT\95160017 FORMS\160_DENT\95160018 FORMS\160_DENT\95160008 FORMS\160_DENT\95160019 FORMS\160_DENT\95160020 2

Dental Hygiene Note FORMS\160_DENT\96160001 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\95136015 FORMS\119_PHAR\95119001 FORMS\111_MEDI\03111002 FORMS\111_MEDI\03111001 FORMS\113_PATH\95113006 FORMS\136_CONS\95136016 FORMS\111_MEDI\95111008 FORMS\111_MEDI\95111001 FORMS\136_CONS\95136036 FORMS\136_CONS\96136003 FORMS\118_NURS\03118007 FORMS\119_PHAR\95119002 FORMS\111_MEDI\97111004 FORMS\111_MEDI\95111024 FORMS\111_MEDI\03111003 FORMS\116_MENT\95116006 FORMS\122_SOCI\96122003 FORSM\117_NURS\04117001 FORMS\117_NURS\01117003 LONG TERM CARE /NURSING HOME LTC Rehab Note FORMS\118_NURS\97118001 Nurse LTC Note FORMS\118_NURS\95118014 Nurse LTC Referral Summary FORMS\118_NURS\97118010 Nursing Home Referral ** FORMS\122_SOCI\95122007 Physician s CNH Referral ** FORMS\111_MEDI\97111005 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\03116001 FORMS\116_MENT\03116002 FORMS\116_MENT\96116001 FORMS\116_MENT\95116004 FORMS\116_MENT\98116001 FORMS\116_MENT\95116009 FORMS\116_MENT\03116005 FORMS\116_MENT\03116006 FORMS\116_MENT\03116008 FORMS\116_MENT\03116007 3

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\04116001 FORMS\116_MENT\04116002 FORMS\116_MENT\95116007 FORMS\116_MENT\95116008 FORMS\116_MENT\97116001 FORMS\116_MENT\95116002 FORMS\116_MENT\02116001 FORMS\116_MENT\02116002 FORMS\116_MENT\03116003 FORMS\116_MENT\95116003 FORMS\116_MENT\02116003 FORMS\116_MENT\02116004 FORMS\116_MENT\03116009 FORMS\116_MENT\04116003 FORMS\116_MENT\03116004 FORMS\122_SOCI\95122003 FORMS\122_SOCI\95122005 FORMS\116_MENT\97116002 FORMS\116_MENT\01116001 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\03118004 FORMS\118_NURS\04118005 FORMS\118_NURS\04118004 FORMS\118_NURS\97118009 FORMS\118_NURS\00118002 FORMS\118_NURS\03118001 FORMS\118_NURS\03118002 FORMS\118_NURS\03118003 FORMS\118_NURS\04118007 FORMS\118_NURS\03118006 FORMS\118_NURS\04118001 FORMS\118_NURS\04118002 FORMS\118_NURS\04118003 FORMS\118_NURS\96118007 FORMS\118_NURS\97118004 FORMS\118_NURS\95118012 FORMS\118_NURS\00118001 FORMS\118_NURS\04118006 FORMS\120_NUTR\95120006 FORMS\120_NUTR\95120005 FORMS\120_NUTR\95120003 FORMS\120_NUTR\95120004 FORMS\120_NUTR\95120002 FORMS\119_PHAR\95119003 4

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\98111006 FORMS\118_NURS\97118002 FORMS\111_MEDI\03111006 FORMS\117_NURS\01117001 FORMS\117_NURS\97117001 FORMS\117_NURS\02117001 FORMS\117_NURS\01117002 FORMS\117_NURS\95117002 FORMS\117_NURS\98117001 FORMS\118_NURS\95118016 FORMS\111_MEDI\98111005 FORMS\118_NURS\03118005 FORMS\111_MEDI\00111001 FORMS\111_MEDI\00111002 FORMS\119_PHAR\96119001 FORMS\111_MEDI\97111008 FORMS\111_MEDI\96111013 FORMS\118_NURS\97118008 FORMS\118_NURS\97118007 FORMS\118_NURS\97118006 FORMS\111_MEDI\95111022 FORMS\111_MEDI\01111003 FORMS\111_MEDI\95111003 FORMS\111_MEDI\95111002 FORMS\111_MEDI\95111021 FORMS\111_MEDI\96111004 FORMS\111_MEDI\02111002 FORMS\118_NURS\00118003 FORMS\112_SURG\95112007 FORMS\112_SURG\97112002 FORMS\112_SURG\97112003 FORMS\119_PHAR\97119001 FORMS\118_NURS\01118003 FORMS\118_NURS\95118010 FORMS\111_MEDI\04111001 FORMS\111_MEDI\96111012 FORMS\116_MENT\02116005 FORMS\111_MEDI\95111005 5

Rheumatology Exam & Minor Procedure Note ** FORMS\117_NURS\95117004 6

SUBSTANCE ABUSE Addictions Treatment Center Note ** Nurse Substance Abuse Admission Screen CIWA Withdrawal ** Substance Abuse Admission FORMS\116_MENT\98116002 FORMS\118_NURS\01118001 FORMS\122_SOCI\95122008 FORMS\116_MENT\97116003 SURGICAL/PROCEDURES/ANESTHESIA Anesthesia Pre/Post Op Assessment ** FORMS\112_SURG\95112006 Informed Consent Note FORMS\116_MENT\96116003 Invasive Procedure Note ** FORMS\112_SURG\95112002 Minor Operative Note ** FORMS\112_SURG\95112003 Nurse Med/Surg Observation FORMS\112_SURG\04112001 Post Op Progress Note ** FORMS\112_SURG\01112001 Special Procedure Note ** FORMS\118_NURS\96118006 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

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

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