FPM Toolbox

Encounter Forms

Acute Knee Injury Encounter Form

An evidence-based encounter form for acute knee injury
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Acute Otitis Media (AOM) Encounter Form

An evidence-based encounter form for acute otitis media
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Algorithm for the Treatment of CA-MRSA

Materials to help with the evaluation and treatment of CA-MRSA
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Asthma Visit Documentation Form

A documentation form to identify important elements of care that are recommended for asthma visits
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Common Skin Procedure Form

An encounter form to simplify documenting and coding common skin procedures
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E/M Visit Encounter Form

A progress note for E/M visits that includes a checklist designed to make it easier to count systems and body areas
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Emergency Nursing Record

A form for recording the details of an office-based emergency
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Encounter Form: House Call - Medicare

A progress note that guides physicians through the necessary home assessment, encourages accurate coding and helps document the necessity of the home visit
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Encounter Form: Well-Male Exam

A well-male exam encounter form that includes a patient-completed history, an exam documentation template and evidence-based screening test recommendations for all age groups
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Encounter Form: Well-Woman Exam (one-page)

A visit-specific encounter form that shifts the responsibility for collecting patients’ health information to the patient and gives physicians more time during the encounter for preventive counseling or patient education
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Encounter Form: Well-Woman Exam (three-page)

A well-woman exam encounter form that includes a patient-completed history, an exam documentation template and evidence-based screening test recommendations for all age groups
Download Format : Word PDF
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Group Visit Documentation Form (Nursing Home)

An encounter form for documenting the history of present illness and physical exams at nursing-home group visits
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Hypertension Encounter Form

An evidence-based encounter form for evaluating hypertension
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Medicare Initial Preventive Physical Examination Encounter Form

An encounter form to ensure all elements of the initial preventive physical exam ("Welcome to Medicare physical") are completed
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Medicare Preventive Physical Exam

An encounter form that details the components required for Medicare annual wellness visits
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Nursing Home Documentation Form

A one-page form that standardizes and simplifies clinician documentation of nursing home care
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Pertussis Screening Form

A form to use throughout the process of contacting and treating patients who might have been exposed to pertussis
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Pulmonary Embolism Encounter Form

An evidence-based encounter form for pulmonary embolism
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Routine Diabetes Encounter Form

An encounter form for use in documenting diabetes-related visits and ensuring that key issues are not overlooked during the visit
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Skin Care Encounter Form

An encounter form for rapidly and accurately reporting skin-related diagnoses and associated procedures
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Sore Throat Encounter Form

An evidence-based encounter form for sore throats
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Type 2 Diabetes Progress Note for Group Visits

An encounter form designed to enable physicians to complete much of their documentation prior to a diabetes group visit
Download Format : Word PDF
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Upper Respiratory Infection Encounter Form

An encounter form for patients with upper respiratory infection symptoms that includes a patient questionnaire section and a physician evaluation section
Download Format : Word PDF
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