This is a form designed as an all purpose standardized template to be used by primary care doctors for acute and chronic visits. It attempts to replicate the natural clinical workflow of an office exam. Clinical decision support is embedded throughout the form in clinically appropriate locations to support diabetic, health maintenance and cardiovascular guidelines.
Purpose
To standardize documentation and provide clinical decision support at the point of care
Ages
This form was created primarily for adults seen for office visits. It is used both for acute and chronic problems. The clinical decision support is geared specifically for adults. This form could be used for all other age groups but elements of it would not be particularly appropriate for younger patients.
Special Features
Standard SOAP format
Pull forward histories
Risk page with smoking cessation supports
Smoking cessation support
ROS with pre-sets and CDS specific to the patient
PE with previous buttons
Assessment with pull forward of last assessment
Plan with dynamic medication list handout and instructions for patient, pull forward previous plan
E/M coding cheat sheet
Sources of Evidence for Clinical Decision Support
USPSTF
NCQA
Notes
This form was developed for use within The Capital Region Health Care system. We make no claims as to its accuracy or clinical content; therefore, testing is suggested prior to implementation within the clinical environment. This form or its clinical decision support is not meant to replace clinical judgement. Verfication of the accuracy of the clinical content and decision support is the sole responsiblity of the user.
*The term "Clinical Kit" is an industry standard amongst Centricity physician office EMR users. It refers to a group of items which can be imported into any Centricity physician office EMR. The zip file contains the general office visit encounter form. This form has many point of care clinical decison support tools for preventive health.
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