Email UpdatesThe 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 Creation and Usage
Please contact Mr. Apurva Desai Apurva.desai@va.gov for additional information.
Copyright © 2018 Veterans Health Administration, Department of Veterans Affairs. All rights reserved. Contributions from external parties are property of respective copyright holders.
Structured code that is interpretable by a computer (includes data elements, value sets, logic)
- Target User
- Primary Care Clinical Providers
- Patient Age Group
- Adult outpatients
- Clinical Venue
- Outpatient
- Clinical Venue
- Primary Care Clinic
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.
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/
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/
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