最新如何制作医学主题PPT模板教学课件.ppt

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1、如何制作医学主题如何制作医学主题PPTPPT模板模板Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布ProblemA familiar lament.“No matter how much I write in my history and physical exam note,I never seem to document enough to substantiate a high level en

2、counter!”Medical documentation is not about HOW MUCH you write!It is about WHAT you write!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation

3、 tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Brought to you by e-Medtoo

4、ls and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical document

5、ation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布How Much Is At Stake?Fact33-52%of patient encounters are UNDER coded (JABFP 2001;14:184-92 and FPM October 2003“How to get all the 99214s you deserve”)Differences in Medicare reimbursement 99214-99215=$30 99214-99213=$30 If you see 30 patients per day you may los

6、e$300 or more per day!33%(30 patients/day)x$30/patient=$300/dayWorking 5 days/week for 50 weeks,that is a potential loss of$75,000 in just 1 year due to inadequate coding!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布What Is

7、The Gain?Decreasing billing and coding errors by just 50%could mean an increase of nearly$40,000 per year in practice revenues!The equivalent of seeing an additional 690 patients/yearOr,an extra 3 patients/day!WITHOUT THE EXTRA WORK!Brought to you by e-Medtools and MedicalTemplatesPhysician designed

8、 medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Benefits of MedicalTemplatesqEasy to useqLegibleqFast and simple to complete qSaves dictation and transcription costsqFast and simple to implement in any practiceqStandardizes documentationqEnhances risk management strategiesqReduces the risk of

9、down codingvWhen documentation is appropriate for billing code Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Professional,Medical and Legal BenefitsLegible,thorough,and standardized documentation is a proven strategy to reduc

10、e riskvThorough documentation becomes the standard of carevImproved,thorough documentation can supportAudits of Billing codeswhen correct code is billed for level of documentationMandatory Quality reportingPay For PerformanceQuality Assurance projectsMaintenance of Certification projectsSelf evaluat

11、ion of practice performance ABIM Practice Improvement ModuleBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布A Quick Review of Medical DocumentationRequirementsBrought to you by e-Medtools and MedicalTemplatesPhysician designed

12、medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Patient Encounters The Centers for Medicare and Medicaid Services(CMS)has published definitions and documentation guidelines for the key components of a medical encounter note,using CPT codes.Brought to you by e-Medtools and MedicalTemplatesPhysic

13、ian designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Key Components of DocumentationHistoryExamMedical Decision MakingCounselingCoordination of CareNature of Presenting ProblemTime1997 Guidelines for Evaluation&Management Services http:/www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdfK

14、ey components in selecting the level of E/M servicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布The HistoryBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发

15、发布布布布History Components and Levels HPIROSPFSHType of HistoryBriefN/AN/AProblem FocusedBriefProblem pertinentN/AExpanded Problem FocusedExtendedExtendedPertinentDetailedExtendedCompleteCompleteComprehensiveNew patient evaluations MUST have at least a Detailed HistoryBrought to you by e-Medtools and M

16、edicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布History of Present IllnessEVERY encounter MUST contain a Chief Complaint!vPreferentially stated in patients wordsElements of HPILocationQualitySeverityDurationTimingContextModifying factorsAssociated Signs and Sym

17、ptomsBriefContains 1-3 elements listed ExtendedContains 4 elementsOR discusses 3 chronic or inactive conditionsBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Review of SystemsConstitutional SymptomsEyesEars,Nose,Mouth,ThroatCa

18、rdiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/ImmunologicProblem PertinentDocuments responses to the system directly related to the presenting problemExtendedDocuments positive and negative responses to 2-

19、9 systems related to the problemCompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems(10 or more total)Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Past,Fami

20、ly and Social HistoryPast Medical HistoryvIllnesses,Operations,Injuries and TreatmentsFamily Medical HistoryvInclude heritable diseases and those that place the patient at increased riskSocial HistoryvAn age appropriate review of past and current activitiesPertinentDocument at least 1 item from ANY

21、of the 3 areasIt must be directly related to the problems identified in the HPIComplete All initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areasBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理

22、整理整理整理发发布布布布The ExamBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Recognized Single Organ SystemsCardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletal

23、NeurologicPsychiatricRespiratorySkinDetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related areaComprehensiveA general multi-system examA complete exam of an organ system and other related body areas or organ systemsMost levels require a minimum o

24、f a Detailed ExamBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Multi-organ System ExamDetailed3 vital signsBP,sitting or standingBP,supinePulse,rate and regularityRespirationsTemperatureHeightWeight2 elements*of at least 6 or

25、gan systems or body areas examinedOR 1 element of at least 12 organ systemsComprehensive2 elements*in at least 9 organ systems or body areas*Refer to 1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧

26、忧PPTPPT整理整理整理整理发发布布布布Single Organ System ExamDetailedvDocument 12 elements*(NOT Eye and Psychiatric exams)vEye and Psych exams document 9 elementsComprehensivevDocument ALL elements*Refer to 1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician

27、designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Elements of Individual Organ SystemsConstitutionalVital signsGeneral appearance of patientNutrition,Body habitus,Development,Deformities,GroomingEyesInspection of conjunctivae and lidsExam of pupils and irisesOphthalmoscopic exam of optic

28、 discsEars,Nose,Mouth and ThroatExternal inspection of ears and noseOtoscopic examAssessment of hearingInspection of nasal mucosa,septum,and turbinatesInspection of lips,teeth and gumsExam of oropharynxNeckExam of neckThyroidRespiratoryAssessment of effortPercussion of chestAuscultationPalpation of

29、chestCardiovascularPalpation of heartAuscultationCarotid artery examAbdominal aorta examFemoral arteries examPedal pulses examExtremities for edema or varicosities Chest(Breasts)InspectionPalpationGastrointestinalAbdominal examLiver and spleen examHernia presence or absenceAnus,perineum,rectum examS

30、tool for occult blood1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Exam elements,continuedLymphaticNeckAxillaGroinOtherMusculoskeletalGait and stationInspection,palpation digi

31、ts and nailsExam of bones,joints,muscles AND 1 or moreInspection or palpationRange of motion and presence/absence of painStabilityMuscle strength and toneSkinInspectionPalpationNeurologicCranial nervesDeep tendon reflexesSensationPsychiatricJudgment and insightOrientation to person,time,placeMemory,

32、recent and remoteMood and affectGenitourinary MaleScrotal contentsPenisDigital rectal exam of prostate glandFemaleExternal genitaliaUrethraBladder examCervixUterusAdnexa/parametria1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed me

33、dical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Medical Decision MakingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Complexity of Medical Decision MakingNumber of DiagnosesOr Management OptionsAmount and/or Complexity of

34、Data to be ReviewedRisk of Complications and/or Morbidity or MortalityComplexity of Decision MakingMinimalMinimal or NoneMinimalStraightforwardStraightforwardLimitedLimitedLowLowLowMultipleModerateModerateModerateModerateExtensiveExtensiveHighHighHighBrought to you by e-Medtools and MedicalTemplates

35、Physician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Examples ofDocumentation Requirements Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Initial Hospital CareMust meet all criteria 99223Comprehensive Histor

36、y and ExamHigh complexity Medical decision making99222Comprehensive History and ExamModerate complexity Medical decision making99221Detailed OR Comprehensive History and ExamStraightforward or Low Complexity Medical decision making Brought to you by e-Medtools and MedicalTemplatesPhysician designed

37、medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Initial Inpatient ConsultationMust meet all criteria99255Comprehensive History AND ExamHigh complexity medical decision making99254Comprehensive History AND ExamModerate complexity medical decision making99253Detailed History AND ExamLow complexit

38、y medical decision makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布New Outpatient EncounterNot a ConsultNot a ConsultMust meet all criteria99205vComprehensive History and ExamvHigh complexity medical decision making99204v

39、Comprehensive History and ExamvModerate complexity medical decision making99203vDetailed History and ExamvLow complexity medical decision makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布New Outpatient ConsultMust meet all

40、 criteria99245vComprehensive HistoryvComprehensive ExamvHigh complexity medical decision making99244vComprehensive HistoryvComprehensive ExamvModerate complexity medical decision making99243vDetailed HistoryvDetailed ExamvLow complexity medical decision makingBrought to you by e-Medtools and Medical

41、TemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布Established Outpatient EncounterMust meet 2 out of 3 criteria99215 vComprehensive HistoryvComprehensive ExamvHigh complexity medical decision making99214vDetailed HistoryvDetailed ExamvModerate complexity medical decisi

42、on making99213vExpanded Problem Focused HistoryvExpanded Problem Focused ExamvLow complexity medical decision makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools无无无无忧忧PPTPPT整理整理整理整理发发布布布布We hope you found this presentation helpful!We are grateful to all the patient and knowledgeable billing and coding specialists we have encountered along the way!We welcome your comments at www.e-