CDS Connect: Primary Care: General Clinical Note - History and Physical Exam Documentation Template

Primary Care: General Clinical Note - History and Physical Exam Documentation Template

Description

The intent of the “General Clinical Note - History and Physical Exam Documentation Template” is to facilitate documentation of information obtained during an initial primary care new patient visit. The documentation template includes the following sections: Chief complaint, history of present illness, review of systems, sexual assault, annual screening questionnaire, and health literacy assessment.

Artifact Type
Creation Date
Version
1.0
Unique Identifier
5e1276d7-e331-5dd6-a774-4404ab0b36d0
Status
Experimental
True

Artifact Creation and Usage

Contributors
Angela Denietolis, MD, Primary Care Physician, James A. Haley Veterans Hospital, Tampa VAMC, Tampa, FL 33612
Pat Dumas, RN, Clinical Program Director, VACO, 810 Vermont Ave NW, Washington, DL 20420
Manish Merchant, MD, Health Informatician, Albany VAMC, 113 Holland Ave., Albany, NY 12208
Timothy Dresselhaus, MD, San Diego VAMC – MEDS, 3350 La Jolla Village Drive, San Diego, CA 92161
David Douglas, MD, Facility Chief Health Informatics Officer, COS - Northwest Innovation Center, Portland VAMC, 3710 SW US Veterans, Hospital Road, Portland, OR 97239

Please contact Mr. Apurva Desai Apurva.desai@va.gov for additional information.

License
IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights

Copyright © 2018 Veterans Health Administration, Department of Veterans Affairs. All rights reserved. Contributions from external parties are property of respective copyright holders.

Implementation Details
Technical Files
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Usage

 

Target User
Primary Care Clinical Providers
Patient Age Group
Adult outpatients
Clinical Venue
Outpatient
Clinical Venue
Primary Care Clinic

 

Cautions

THE CLINICAL CONTENT IN THIS DOCUMENT IS NOT DIRECTLY SUITABLE FOR CLINICAL USE AS PRESENTED SINCE IT HAS NOT BEEN TESTED IN A CLINICAL ENVIRONMENT. IT HAS NEVER BEEN PILOTED, NEVER 100% REPRESENTS THE INTENT OF THE CLINICAL SUBJECT MATTER EXPERTS, AND MAY CAUSE HARM IF APPLIED AS-IS. THIS WORK IS MADE AVAILABLE WITHOUT ANY WARRANTY WHATSOEVER, AND WITHOUT CLAIMS, EXPRESSED OR IMPLIED, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.

Supporting Evidence
Source Description

 

See attached resource files for additional details. Department of Veterans Affairs, Veterans Health Administration, Office of Informatics and Information Governance, Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs) Eye Care Clinical Content White Paper, VA118-16-D-1008, Task Order VA-118-16-F-1008-0007, June, 2018.

Denny JC, Miller RA, Johnson KB, Spickard A. Development and evaluation of a clinical note section header terminology. AMIA Annu Symp Proc 2008. 2008;:156-160
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656032/#
Goetzel RZ, Staley P, Ogden L, et al. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. A framework for patient-centered health risk assessments – providing health promotion and disease prevention services to Medicare beneficiaries. Centers for Disease Control and Prevention Website. Published 2011 Accessed August 29, 2017
https://www.cdc.gov/policy/hst/hra/frameworkforhra.pdf
National Center for Health Promotion and Disease Prevention. Get Recommended Screening Tests and Immunizations for Men. Accessed August 29, 2017
https://www.prevention.va.gov/Healthy_Living/Get_Recommended_Screening_Tests_and_Immunizations_for_Men.asp
Get Recommended Screening Tests and Immunizations for Women. National Center for Health Promotion and Disease Prevention. Accessed August 29, 2017
https://www.prevention.va.gov/Healthy_Living/Get_Recommended_Screening_Tests_and_Immunizations_for_Women.asp
Medicare coverage and payment of the annual wellness visit providing a personalized prevention plan under Medicare Part B. FedRegist. 2011;76(228):42 CFR §410, §414, §415, and §495.
https://www.ecfr.gov/cgi-bin/text-idx?SID=fba3a01d98c4f85620f655426db549f5&mc=true&tpl=/ecfrbrowse/Title42/42chapterIV.tpl
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The Opioid Therapy for Chronic Pain Work Group. Published February 2017
https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf
USPSTF A and B Recommendations. U.S. Preventive Services Task Force. Updated April 2017
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

 

References

 

See attached resource files for additional details. Department of Veterans Affairs, Veterans Health Administration, Office of Informatics and Information Governance, Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs) Eye Care Clinical Content White Paper, VA118-16-D-1008, Task Order VA-118-16-F-1008-0007, June, 2018.

Denny JC, Miller RA, Johnson KB, Spickard A. Development and evaluation of a clinical note section header terminology. AMIA Annu Symp Proc 2008. 2008;:156-160
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656032/#
Goetzel RZ, Staley P, Ogden L, et al. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. A framework for patient-centered health risk assessments – providing health promotion and disease prevention services to Medicare beneficiaries. Centers for Disease Control and Prevention Website. Published 2011 Accessed August 29, 2017
https://www.cdc.gov/policy/hst/hra/frameworkforhra.pdf
National Center for Health Promotion and Disease Prevention. Get Recommended Screening Tests and Immunizations for Men. Accessed August 29, 2017
https://www.prevention.va.gov/Healthy_Living/Get_Recommended_Screening_Tests_and_Immunizations_for_Men.asp
Get Recommended Screening Tests and Immunizations for Women. National Center for Health Promotion and Disease Prevention. Accessed August 29, 2017
https://www.prevention.va.gov/Healthy_Living/Get_Recommended_Screening_Tests_and_Immunizations_for_Women.asp
Medicare coverage and payment of the annual wellness visit providing a personalized prevention plan under Medicare Part B. FedRegist. 2011;76(228):42 CFR §410, §414, §415, and §495.
https://www.ecfr.gov/cgi-bin/text-idx?SID=fba3a01d98c4f85620f655426db549f5&mc=true&tpl=/ecfrbrowse/Title42/42chapterIV.tpl
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The Opioid Therapy for Chronic Pain Work Group. Published February 2017
https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf
USPSTF A and B Recommendations. U.S. Preventive Services Task Force. Updated April 2017
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

 

Artifact Representation
Testing Experience
Pilot Experience

None