SAMPLE DOCUMENTATION
TEMPLATES
UPHS – Department of Medicine
Subsequent Inpatient Visit Note
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UPHS – Department of Medicine
Subsequent Inpatient Visit Note
(Requires 2 of 3 components: history, exam, or medical decision making)
Date: _____________ Time: ___________ Patient Name:
(1) INTERVAL HISTORY: HPI: Level 3 = ≥ 4; Level 1 - 2 = ≤ 3 MEDICATIONS:
ROS: Level 3 = 2 - 9; Level 2 = 1; Level 1 = 0 ■ unchanged from ______________________
location/quality/duration/timing/severity/context/mod factors/assoc s/s
■ unable to obtain (indicate reason)
■ unchanged from ______________
(2) MULTI-SYSTEM EXAM: (any 12 = Level 3; any 6 = Level 2; ≤any 5 = Level 1) Elaborate Abnormal Findings
Constitutional: Lymphatic: no adenopathy (indicate at least two, if applicable)
■ (Document 3) T: ____ P: ____ BP: ____ RR: ____ WT: ____ ■ cervical ■ axillary ■ inguinal ■ supraclavicular
■ See Vital Sign Flow Sheet
■ APPEARANCE: ____________________________________ Musculoskeletal: ■ nl gait
■ no clubbing, cyanosis
Eyes: ■ no scleral icterus ■ nl muscle strength and tone
■ PERRLA
Skin: ■ no rash or ulcers
Ears/Nose/Mouth/Throat: ■ nl teeth, lips, gums
■ no nodules
■ clear oropharynx
Neck: ■ nl appearance and movements; nl JVP Neuro: ■ non-focal
■ trachea midline ■ nl sensation
■ no thyroid enlargement, masses
Psych: ■ alert, oriented to person, place, time
Respiratory: ■ symmetrical chest expansion and respiratory effort ■ nl affect
■ clear to auscultation and palpation
Other:
Cardiovascular: ■ nl sounds; no murmurs, gallops, rubs
■ no edema
Abdominal: ■ no tenderness; nl sounds
■ no hepatosplenomegaly
■ no hernias present
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Patient Name_________________________________________________________________ MRN#______________________________________
(3) MEDICAL DECISION MAKING:
Data Review: (Laboratory/Radiology/Additional Records Reviewed) ■ See Lab Report: Data _______________________
■ See Radiology Report: Data _______________
(Attending reviewed above data ________________)
Assessment/Plan: (Possible Diagnoses/Treatment Options/Additional Testing/Therapeutic Interventions)
Resident/Fellow Signature: ________________________________________________ Date: _____________ Pager: _____________
ATTENDING SUPPLEMENT: (Minimum 1 element from 2 components: history, exam, or medical decision making)
I saw and evaluated the patient, and I agree with note by Dr. __________________________________________.
Counseling and/or Coordination of Care (time_______)
(>50% of Total Floor Time; Spent Face-to-Face with Patient/Family)
Discussion Points:
DNR Status:
Attending Signature/Print: _________________________________________________________ Date: _______________ Time: _______________
Total Attending Floor Time (min): _____________
Subsequent: ■ 99231 (15 min) ■ 99232 (25 min) ■ 99233 (35 min) ■ Prolonged Care: Time ________ (Face-to-Face with Patient Only)
■ Discharge Day: Time __________ ■ Critical Care: Total Cumulative Time __________
■ -25 (Separately identifiable E/M service on procedure day)
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