Patient Notes Templates
Many emergency departments use template notes - they have a huge cabinet with different notes tailored to the chief complaint, e.g. CP note, abdominal pain note, leg pain note, etc. Questions that have to be asked are on the front page and the back page lists the required tests for a particular complaint, differentials and treatment suggestions. Even if you are very tired, you can just glimpse at the note, and you know what to ask and what to order.
T-System offers ER and outpatient template notes. Download an example of DM visit (PDF file). DocAroundTheClock, who is an ER physician, shares his experience with the T-system templates.
I designed my own Sample Admission Notes for the Most Common Conditions, and they are focused on inpatient medicine.
Family Practice Management journal provides similar and even more variable templates in their toolbox section.
For example, you can review and download the ICD codes: FPM Short List of ICD-9 Codes or FPM Long List of ICD-9 Codes
According to Kevin MD, finding ICD-9 codes can be done easily with Google. You can use various ICD-9 databases, but you can also Google for the appropriate code by adding "ICD-9" to the query. This suggestion seems to be best idea because it is the simplest one.
Study Aids for various CWRU clerkships:
5 x 8 index card for tracking your patients' hospital courses and more.
What is High Complexity Medical Decision Making?. KidneyNotes.com.
Patient Care Documentation Forms. ACP Online.
In The Eyes of Medicare, You are a 99223. The Happy Hospitalist, 11/2007.