FPM Toolbox

Download more than 150 free practice management tools -- from coding cheat sheets to HIPAA authorization forms to Medicare annual wellness visit resources.

Browse by category:

Interactive versions of selected tools are provided by soapnote.org, a web site not affiliated with the AAFP. Simply click on the "interactive version" link beneath the tool's title.

Chart audit tool
An Excel spreadsheet that helps a practice conduct a chart audit to determine whether it is billing and getting paid for the appropriate services
Download format: MS Excel
Source article

Claim correction form
A one-page form that can help make the process of filing corrected claims more efficient
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

FPM superbill
A superbill to capture the codes most common in office-based outpatient practice
Download format: PDF (printer friendly), MS Excel
Source article

Sample patient financial hardship application
An application for patients facing financial hardships and seeking assistance from their doctor's office to pay their medical bills
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Controlled substance refill program: Patient agreement form
An agreement patients sign indicating they understand and will comply with the practice's rules for opioid use
Download format: PDF (printer-friendly)
Source article

Controlled substance refill program: Patient enrollment form
A form used to enroll patients in a practice's program for managing controlled substance refills
Download format: PDF (printer-friendly)
Source article

Medication refill request
A simple form that helps physicians and office staff manage patients' refill requests
Download format: PDF (printer-friendly)
Source article

Post-appointment order sheet
A check-box order sheet that allows you to order tests and then hand off the form to your receptionist to schedule them
Download format: PDF (printer-friendly)
Source article

Refill protocol
A spreadsheet that assists office staff in managing patients' refill requests
Download format: MS Excel
Source article

State-by-state prescribing laws
A list of state laws regarding the maximum length of prescriptions
Download format: PDF (printer-friendly)
Source article

Tracking book for unresolved issues
An example of a tracking book that can be used as a reminder for following up on patients' test results or other unresolved issues
Download format: PDF (printer-friendly)
Source article

Physician self-evaluation
A qualitative self-evaluation for physicians that consists of open-ended questions about their practices
Tool as published
Source article

Physician self-evaluation checklist
A checklist asking physicians to rate themselves on a five-point scale in eight key areas
Tool as published
Source article

Worksheet: Identifying your key job issues
Three exercises to help you identify the key issues to guide your job search
Download format: PDF (printer-friendly)
Source article

Coronary angioplasty
A risk score calculator for estimating the likelihood of complications from angioplasty
Download format: PDF (printer friendly)
Source article

Coronary heart disease
A score sheet for predicting the risk of coronary heart disease in men or women based on total cholesterol level
Download format: PDF (men), PDF (women)
Interactive version
Source article

Coumadin adjustment calculator
A calculator that guides a medical provider through adjustment of coumadin (warfarin) dosing.
Interactive version
Source article

CURB-65 and CRB-65 severity scores for community-acquired pneumonia
A clinical prediction tool to help guide physicians when deciding on inpatient or outpatient treatment of pneumonia
Download format: PDF (printer-friendly)
Interactive version
Source article

Decision rules for knee injury
Two evidence-based decision rules for acute knee injury (Ottawa and Pittsburgh knee rules)
Interactive version
Source article

Immediate Action Protocol for patients at risk of suicide
A protocol for assessing a patient's suicide risk and deciding on an appropriate plan of action, including referral to an inpatient psychiatric facility.
Download format: PDF (printer-friendly)
Source article

Otitis media decision tool
A tool for determining the certainty of diagnosis in children
Interactive version
Interactive version with clinical note
Source article

Pneumonia severity index for community-acquired pneumonia
A clinical prediction tool to help guide physicians when deciding on inpatient or outpatient treatment of pneumonia
Download format: PDF (printer-friendly)
Source article

Strep throat decision tool
A calculator that applies the Centor criteria for pharyngitis
Interactive version
Source article

Coding frequency comparison spreadsheet
A spreadsheet that enables physicians to easily compare their coding frequencies with one another and with national benchmarks
Download format: MS Excel
Source article

Coding from the presenting problem
A table that shows how E/M codes can be based on the presenting problem
Download format: PDF (printer friendly)
Source article

Enhanced pocket guide to the 1997 E/M documentation guidelines
A handy reference to the documentation requirements for new and established patient office visits (codes 99211-99215 and 99201-99205)
Order info

Guidelines for time-based coding
A summary of CPT's prolonged services guidelines and associated average visit times
Download format: PDF (printer friendly)
Source article

House calls
A comparison of new and established patient CPT codes for house calls and similar office visit codes
Tool as published
Source article

Medical decision-making reference
Tables to calculate your level of medical decision making for routine established-patient office visits
Download format: PDF (printer friendly)
Source article

Office visits: Level I
A quick reference for identifying the criteria for documenting a 99201 new patient visit
Tool as published
Source article

Office visits: Level IV
A quick reference for identifying the criteria for documenting a 99214 established patient visit. Two versions are available.
Version #1 (based on the 1997 guidelines; includes the list of general multisystem exam bullets plus reminders for code 99204):
Download format: PDF (printer friendly)
Source article
Version #2 (based on the 1995 guidelines; includes a time-based coding section and patient examples):
Download format: PDF (printer friendly)
Source article

Quantifying the risk of complications, morbidity and mortality
A table for understanding the level of risk associated with common problems, diagnostic procedures and management options
Download format: PDF (printer friendly)
Source article

ICD-9 coding references
Annually updated ICD-9 coding tools, including the FPM Short List of about 600 ICD-9 codes commonly used in family medicine, the FPM Long List of about 1,500 ICD-9 codes and the FPM Superbill.
More information

Asthma
A documentation form to identify important elements of care that are recommended for asthma visits
Download format: PDF (printer friendly)
Source article

Checklist of care plan oversight requirements
A checklist to determine if you have a situation that meets the physician and beneficiary requirements for CPO
Tool as published
Source article

Decision tree for new and established patients
A decision tree for determining if a patient is new or established
Download format: PDF (printer-friendly)
Source article

Documentation requirements for established patient office visits
A table that shows the history, exam and medical decision making requirements for each of the established patient office visit codes
Download format: PDF (printer friendly)
Source article

Documentation requirements for new and established patient office visits
A table that shows the documentation requirements for new and established patient office visits
Tool as published
Source article

Documenting history
A set of tables that show the requirements for documenting the history component for both new and established patient office visits.
Download format: PDF (printer friendly)
Source article

Encounter form: Acute otitis media
An evidence-based encounter form for acute otitis media
Download format: PDF (printer friendly)
Source article

Encounter form: Acute knee injury
An evidence-based encounter form for acute knee injury
Download format: PDF (printer friendly)
Source article

Encounter form: Diabetes
An encounter form for use in documenting diabetes-related visits and ensuring that key issues are not overlooked during the visit
Download format: PDF (printer friendly)
Source article

Encounter form: E/M visit
An encounter form for E/M visits that includes a checklist designed to make it easier to count systems and body areas
Download format: PDF (printer friendly)
Source article

Encounter form: Group visits (diabetes)
An encounter form designed to enable physicians to complete much of their documentation prior to a diabetes group visit
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Encounter form: Group visits (nursing home)
An encounter form for documenting the history of present illness and physical exams at nursing-home group visits
Download format: PDF (printer-friendly), MS Word (modifiable)
Source article

Encounter form: House calls
An encounter form that guides physicians through the necessary home assessment, encourages accurate coding and helps document the necessity of the home visit
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Encounter form: Hypertension
An evidence-based encounter form for evaluating hypertension
Download format: PDF (printer friendly)
Source article

Encounter form: Pulmonary embolism
An evidence-based encounter form for pulmonary embolism
Download format: PDF (printer friendly)
Source article

Encounter form: Sore throat
An evidence-based encounter form for sore throats
Download format: PDF (printer friendly)
Source article

Encounter form: Well-male visit
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
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Encounter form: Well-woman visit (one-page version)
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
Download format: PDF (printer friendly)
Source article

Encounter form: Well-woman visit (three-page version)
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: PDF (printer friendly), MS Word (modifiable)
Source article

Evaluation and management guidelines at a glance
A two-page summary of the documentation guidelines for E/M services
Download format: PDF (printer friendly)
Source article

General multisystem exam documentation reference
A one-pager outlining the documentation requirements for general multisystem exams
Download format: PDF (printer friendly)
Source article

Integrated summary template
A one-page template that summarizes the patient's health by including a problem list, medication list, past medical history, flow-sheet parameters, etc.
Download format: PDF (printer friendly)
Source article

Nursing home documentation form
A one-page form that standardizes and simplifies clinician documentation of nursing home care
Download format: PDF (printer friendly)
Source article

EHR demonstration rating form
A rating form to be completed by each person in your group who observes an EHR vendor demonstration
Download format: PDF (printer friendly)
Source article

EHR five-year cost/benefit & increased annual E/M revenue worksheets
Two worksheets to help you estimate the net annual benefit and the net increase in E/M revenue to be derived from an EHR system either per physician or for a whole practice
Download format: MS Excel
Source article

EHR functionality list
A list to help you organize your priorities in terms of EHR functionality
Tool as published
Source article

EHR user satisfaction survey
FPM's latest survey of user satisfaction with EHR products.
Source article

EHR vendor rating tool
A rating form to evaluate each EHR product your group is considering
Download format: PDF (printer friendly)
Source article

EMR cost-analysis spreadsheet
A spreadsheet that calculates the initial purchase price of a complete electronic medical record (EMR) system as well its annual and five-year operating costs
Download format: MS Excel
Source article

EMR cost-savings calculator
A calculator that helps physicians determine their annual transcription costs
Download format: MS Excel
Source article

EMRs: Evaluation criteria
A list of criteria that electronic medical record (EMR) systems should have to be family-physician friendly
Tool as published
Source article

PDA software evaluation
A worksheet to evaluate the content, time saved and cost-effectiveness of PDA software
Download format: MS Word (modifiable)
Source article

Questions to ask EHR references
A list of questions to ask other practices about their experience with the EHRs you're considering purchasing
Tool as published
Source article

Request for proposal (RFP) outline
An outline that tells your prospective EHR vendor about your practice, its resources and your priorities in terms of EHR functionality
Tool as published
Source article

Fire checklist
An office-fire checklist that addresses what to do before and during a fire
Download format: PDF (printer friendly)
Source article

Fire drill evaluation form
A form for evaluating the effectiveness of an office fire drill
Tool as published
Source article

Off-site necessities kit
A list of materials a practice may need to store off site in case an emergency denies staff access to the office
Tool as published
Source article

Asthma management flowsheet
A flow sheet for tracking key asthma indicators over several visits.
Download format: PDF (printer friendly)
Source article

Encounter form
A documentation form to identify important elements of care that are recommended for asthma visits
Download format: PDF (printer friendly)
Source article

Chart reminder
A reminder to place in the charts of patients with asthma to aid physicians in providing the recommended treatment
Tool as published
Source article

Patient self-assessment form - asthma
A form to help engage asthma patients in their own care.
Download format: PDF (printer friendly)
Source article

Patient self-assessment form - asthma (Spanish)
A form to help engage Spanish-speaking asthma patients in their own care.
Download format: PDF (printer friendly)
Source article

Checkup questionnaire
An annual questionnaire that helps patients with diabetes think about their health care goals and identify areas in which they may need assistance
Download format: PDF (printer friendly)
Source article

Diabetes registry
A sample spreadsheet to track interventions and parameters for diabetes management
Download format: MS Excel
Source article

Encounter form
An encounter form for use in documenting diabetes-related visits and ensuring that key issues are not overlooked during the visit
Download format: PDF (printer friendly)
Source article

Flow sheet
A flow sheet for recording patients’ essential diabetes measures, such as A1c rates, over time
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Patient-physician partnership agreement
An agreement for both a patient with a chronic disease, such as diabetes, and a physician to sign as a step toward better managing a patient's disease
Download format: PDF (printer-friendly)
Source article

Reminder letter
A letter that reminds patients they are due for a diabetes checkup and instructs them of the tests they need to have completed before their visit
Download format: PDF (printer friendly)
Source article

Clinic-level pandemic influenza planning form
A form to estimate the total number of people affiliated with your clinic who might need the pandemic influenza vaccine
Download format: PDF (printer friendly)
Source article

Flu triage form
A form to help nurses identify patients over the phone who may be at high risk for influenza and H1N1
Download format: PDF (printer-friendly)
Source article

Patient priority groups and database parameters worksheet
A form with suggested database search parameters to quickly identify patients in each priority tier group for pandemic influenza vaccines
Download format: PDF (printer friendly)
Source article

Primary care clinic staff worksheet
A worksheet to ensure you’ve accounted for all employees when estimating your clinic’s need for pandemic influenza vaccine
Download format: PDF (printer friendly)
Source article

Acute knee injury
An evidence-based encounter form for acute knee injury
Download format: PDF (printer friendly)
Source article

Acute otitis media
An evidence-based encounter form for acute otitis media
Download format: PDF (printer friendly)
Source article

Asthma
A documentation form to identify important elements of care that are recommended for asthma visits
Download format: PDF (printer friendly)
Source article

Common skin procedure form
An encounter form to simplify documenting and coding common skin procedures
Download format: PDF (printer friendly)
Source article

Diabetes
A progress note for use in documenting diabetes-related visits and ensuring that key issues are not overlooked during the visit
Download format: PDF (printer friendly)
Source article

E/M visit
A progress note for E/M visits that includes a checklist designed to make it easier to count systems and body areas
Download format: PDF (printer friendly)
Source article

Group visits (diabetes)
A progress note designed to enable physicians to complete much of their documentation prior to a diabetes group visit
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Group visits (nursing home)
A progress note for documenting the history of present illness and physical exams at nursing-home group visits
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

House calls
A progress note that guides physicians through the necessary home assessment, encourages accurate coding and helps document the necessity of the home visit
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Hypertension
An evidence-based encounter form for evaluating hypertension
Download format: PDF (printer friendly)
Source article

Medicare initial preventive physical examination encounter form
An encounter form to ensure all elements of the initial preventive physical exam (or "Welcome to Medicare physical") are completed
Download format: PDF (printer friendly)
Source article

Medicare preventive physical exam
An encounter form that details the components required for Medicare annual wellness visits
Download format: PDF (color); PDF (black and white)
Source article

Pertussis screening form
A form to use throughout the process of contacting and treating patients who might have been exposed to pertussis
Download format: PDF (printer friendly)
Source article

Pulmonary embolism
An evidence-based encounter form for pulmonary embolism
Download format: PDF (printer friendly)
Source article

Sore throat
An evidence-based encounter form for sore throats
Download format: PDF (printer friendly)
Source article

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: PDF (printer friendly), MS Word (modifiable)
Source article

Well-male visit
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
Download formats: PDF (printer friendly), MS Word (modifiable)
Source article

Well-woman visit (one-page version)
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
Download format: PDF (printer friendly)
Source article

Well-woman visit (three-page version)
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 formats: PDF (printer friendly), MS Word (modifiable)
Source article

Chart of accounts template
A sample template used to track and compare a practice's expenses
Download format: MS Excel
Source article

E/M vs. procedural services reimbursement spreadsheet
A spreadsheet for analyzing your payers' fees for selected E/M and procedural services
Download format: MS Excel
Source article

Financial analysis: Buying medical equipment
A spreadsheet that helps you estimate the financial feasibility of buying new medical equipment for your practice
Download format: MS Excel
Source article

Financial evaluation matrix
A sample matrix used to compare financial and other measures of numerous practice sites
Download format: MS Excel
Source article

Financial vital signs worksheet
A worksheet to help you monitor your practice's financial health each month and compare your performance to specialty benchmarks
Download format: MS Excel
Source article

Internal control and fraud prevention checklist
A checklist to help practices evaluate their risk of embezzlement
Download format: PDF (printer-friendly)
Source article

Medicare cut impact tool
A tool to estimate the impact a Medicare fee cut would have on your practice
Download format: MS Excel
Source article

Residency program finances
A model for capturing the more elusive contributions a residency program makes to its sponsoring institution
Download format: MS Word (modifiable)
Source article

Unit cost analysis
An example of a unit cost analysis that can be used to calculate your costs per visit
Tool as published
Source article

Asthma management
A flow sheet for tracking key asthma indicators over several visits.
Download format: PDF (printer friendly)
Source article

Depo-progesterone injections
A flow sheet that helps nurses properly document patients' depo-progesterone visits
Download format: PDF (printer friendly)
Source article

Diabetes checkups
A flow sheet for recording patients’ essential diabetes measures, such as A1c rates, over time.
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Outpatient anticoagulation flow sheet
A flow sheet for recording patients' warfarin doses, including a dosage adjustment algorithm and anticoagulation decision support
Download format: PDF (printer friendly)
Source article

Preventive care
Nine flow sheets that help physicians track whether patients of any age have received the necessary preventive care services
Download formats: PDF (printer friendly), MS Word (modifiable)
Source article

Vital signs
A flow sheet that helps nurses document patients’ vital signs in the chart so that physicians can review them efficiently
Download format: PDF (printer friendly)
Source article

Encounter form (diabetes)
An encounter form designed to enable physicians to complete much of their documentation prior to a diabetes group visit
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Encounter form (nursing home)
An encounter form for documenting the history of present illness and physical exams at nursing-home group visits
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Sample invitation
A letter for patients eligible to participate in a practice's group-visit program
Download format: MS Word (modifiable)
Source article

Authorization form
A sample form for obtaining authorization from patients to release their protected health information for reasons other than treatment, payment or health care operations
Download format: MS Word (modifiable)
Source article

Health plan inventory worksheet
A worksheet designed to help physicians organize their HIPAA information and to prepare them to speak with vendors about their HIPAA-readiness
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Notice of privacy practices
A sample notice that informs patients of their privacy rights and the practice's privacy policies and procedures
Download format: MS Word (modifiable)
Source article

Standardized admission orders
A set of 29 ready-made admission orders for conditions ranging from ASA overdose to chest pain to diabetic ketoacidosis
Download format: PDF (printer friendly), MS Word (modifiable)
Source article

Compassion fatigue
Nine yes or no statements that can help a physician assess his or her risk for compassion fatigue
Tool as published
Source article

Time-management exercise
A quick time-management exercise that shows physicians exactly where they are spending the 168 hours of their week
Tool as published
Source article

Cheat sheet: Formulary
A sample pocket card that indicates health plan's formulary restrictions in nine common drug classes and provides initial doses and dosage ranges
Tool as published
Source article

Cheat sheet: Health plan requirements
A sample cheat sheet that summarizes the requirements of an individual insurance plan and can be attached to charts prior to appointments
Download format: MS Word (modifiable)
Source article

Fee analysis spreadsheet
A spreadsheet to help you identify which reimbursement rates should be negotiated with payers and a corresponding revenue-analysis spreadsheet to help you assess your profits if a payer accepts your target rate
Download format: MS Excel
Source article

Letter to health plans about bundling services
A sample letter to health plans about the inappropriate bundling of preventive medicine services and problem-oriented E/M services on the same date
Download format: MS Word
Source article

Matrix: Ancillary services
A quick reference, based on the patient's insurance, for determining which ancillary center to refer to and how to bill for the service
Tool as published
Source article

Patient panel size worksheet
A worksheet to help you calculate your current and ideal panel size
Download format: MS Excel
Source article

Pay-for-performance evaluation tool
A spreadsheet that can help you evaluate the pay-for-performance programs that are available to you
Download format: MS Excel
Source article

Response to a health plan audit
A sample response to a health plan that identifies you as a coding outlier
Download format: MS Word (modifiable)
Source article

Spreadsheet: Health plan comparison
A sample spreadsheet that directly compares the value of the health plans a practice does business with
Download format: MS Excel
Source article

Checklist of care plan oversight requirements
A checklist to determine if you have a situation that meets the physician and beneficiary requirements for CPO
Tool as published
Source article

E/M services Q&A: How does your Medicare administrative contractor interpret the guidelines?
A reference outlining contractor rules on various portions of Medicare's Documentation Guidelines for Evaluation and Management Services
Download format: PDF (printer friendly)
Source article

Medicare cut impact tool
A tool to estimate the impact a Medicare fee cut would have on your practice
Download format: MS Excel
Source article

Medicare opt-out notice
An agreement form to notify Medicare that you plan to opt out
Download format: PDF (printer friendly)
Source article

Private contract with Medicare beneficiary
A contract between you and Medicare patients that they are prohibited from submitting claims to Medicare for reimbursement for services you provide
Download format: PDF (printer friendly)
Source article

Wellness care - letter to patients
A sample letter to patients explaining Medicare wellness care
Download format: PDF (printer friendly)
Source article

Wellness care - Medicare checkup
A health risk assessment Medicare patients can complete as part of their annual wellness visits
Download format: PDF (printer friendly)
Source article

Wellness care - Medicare initial preventive physical examination encounter form ("Welcome to Medicare physical")
An encounter form to ensure all elements of the initial preventive physical exam are completed
Download format: PDF (printer friendly)
Source article

Wellness care - Medicare preventive physical exam ("Annual wellness visit")
An encounter form that details the components required
Download format: PDF (color); PDF (black and white)
Source article

Wellness care - Scheduling resource for Medicare wellness visits
A resource to help schedulers communicate with Medicare patients regarding wellness visits
Download format: PDF
Source article

Dismissal letter for patients with delinquent accounts
A sample letter to notify patients of their dismissal from the practice due to the outstanding balance on their account
Download format: MS Word (modifiable)
Source article

Flow chart for managing difficult physician-patient relationships
A flow chart to help physicians deal with challenging patients and advise them when it is necessary to terminate the relationship
Download format: PDF (printer friendly)
Source article

Notice regarding same-day wellness care and illness care
A sample notice to explain your office’s policy of scheduling problem-oriented visits and preventive visits on separate dates
Download format: MS Word
Source article

Payment policy
An example of a payment policy that lets patients know what the practice expects of them financially and that gives the practice some legal protection if necessary
Download format: MS Word (modifiable)
Source article

Sexual harassment
Sample sexual harassment policies for family practices
Tool as published
Source article

Warning letter for patients with delinquent accounts
A sample letter to warn patients that their account will be sent to a collection agency
Download format: MS Word (modifiable)
Source article

Avoiding counterfeit drugs
A handout to advise your patients on how to avoid purchasing counterfeit medicines
Download format: PDF (printer-friendly)
Source article

Blood pressure
A sample patient handout that helps patients focus on their health care goals by listing critical measures for their condition, explaining what those numbers mean and offering strategies for improvement
Tool as published
Source article

Evaluating the need for an interpreter (Spanish)
A patient handout that will help explain to Spanish-speaking patients what they can expect when using an interpreter. (An English translation is also available.)
Download format: PDF (printer-friendly)
Source article

First visit
A handout that can be mailed to new patients prior to their first visit to acquaint them with the practice
Download format: MS Word (modifiable)
Source article

Health plan's rules
A patient handout that explains the general rules associated with referrals, preauthorizations, formularies and participating providers
Download format: PDF (printer friendly)
Source article

Insurance coverage
A patient handout that explains the concepts and financial implications of medical necessity and medical benefits and covered and noncovered services
Download format: PDF (printer friendly)
Source article

Medical bills
A patient handout that assists physicians in dealing with questions patients may ask and with problems that arise when patients misunderstand their insurance benefits
Download format: PDF (printer friendly)
Source article

Medical error prevention
A patient handout that provides 20 tips for preventing medical errors
Download format: PDF (printer friendly)
Source article

Medication use agreement
A form that patients being prescribed drugs for chronic pain can sign to signal their agreement not to misuse the drugs
Download format: PDF (printer friendly)
Source article

Mourners' rights
A patient-education handout that helps prevent health crises in mourning patients and demonstrates that the physician cares
Download format: PDF (printer friendly
Source article

Patient assistance contract
A contract to help patients enrolled in pharmaceutical assistance programs understand their responsibilities
Download Format: PDF (printer friendly), MS Word (modifiable)
Source article

Patient-physician partnership agreement
An agreement for both a patient with a chronic disease, such as diabetes, and a physician to sign as a step toward better managing a patient's disease
Download format: PDF (printer friendly)
Source article

Patient welcome
A sample welcome letter for new patients at their first office visit
Download format: MS Word (modifiable)
Source article

Payment policy
An example of a payment policy that lets patients know what the practice expects of them financially and that gives the practice some legal protection if necessary
Download format: MS Word (modifiable)
Source article

Prescriptions
A patient handout that explains the concepts and financial implications of formularies, preferred and nonpreferred drugs and brand name and generic drugs
Download format: PDF (printer friendly)
Source article

Prescription assistance
A patient handout that describes how patients can get medicine for a reduced cost
Download format: PDF (printer friendly)
Source article

Scope of practice
A sample poster that describes the variety of services a family practice offers
Tool as published
Source article

Specialty referrals and managed care
A patient handout that clarifies the details of specialty referrals and managed care
Download format: MS Word (modifiable)
Source article

Sports physicals
A patient handout to explain to parents why they may need to schedule a well-child exam rather than a "sports physical" for their child
Download format: MS Word (modifiable)
Source article

Visit summary
An information sheet that summarizes the most important points of the patient’s visit and explains what he or she needs to do after leaving your office
Download format: PDF (printer friendly)
Source article

Warfarin dose reminder chart
A chart to help patients remember the correct dose of warfarin
Download format: PDF (printer friendly)
Source article

Adult health questionnaire
A list of basic health care questions for new patients designed to gather the patient's history, initiate a dialogue for the exam and help the patient feel more comfortable with a new physician
Tool as published
Source article

Diabetes checkup questionnaire
An annual questionnaire that helps patients with diabetes think about their health care goals and identify areas in which they may need assistance
Download format: PDF (printer friendly)
Source article

Genogram template
A genogram template for patients' family relationships and medical history that can provide a quick and useful context in which to evaluate an individual's health risks
Download format: PDF (printer friendly)
Source article

Patient phone-system survey
A survey that asks patients to evaluate the efficiency of a practice's phone system
Download format: PDF (printer friendly)
Source article

Patient satisfaction survey
A sample survey practices can use to measure patient satisfaction
Download format: PDF (printer friendly)
Source article

Patient self-assessment form - asthma
A form to help engage asthma patients in their own care.
Download format: PDF (printer friendly)
Source article

Patient self-assessment form - asthma (Spanish)
A form to help engage Spanish-speaking asthma patients in their own care.
Download format: PDF (printer friendly)
Source article

Pre-appointment questionnaire
A questionnaire to help you understand the patient's primary agenda for the visit
Download format: PDF (printer-friendly)
Source article

Problem-solving worksheet
A worksheet to help patients set goals that will help them tackle their health problems
Tool as published
Source article

Survey of patient Internet/e-mail capability and interest
A survey to identify patients' ability to communicate with your practice via the Internet
Download format: PDF (printer-friendly)
Source article

Today's visit checklist
A brief checklist for patients that helps them focus their goals for the current visit
Download format: MS Word (modifiable)
Source article

Cause and effect diagram
A diagram to resolve a problem in your office that is created by breakdowns in process
Tool as published
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Chart audit: Nomogram for determining sample size
A table for determining the number of charts you will need to review to achieve a statistically valid sample.
Tool as published
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Chart review: Self-audit form
A form used to evaluate progress notes to determine whether the documentation supports the coding
Download format: PDF (printer friendly)
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Chart review: Template for findings
A sample template used for recording chart-review findings on influenza vaccinations
Tool as published
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Flow map
A map to depict the steps of a process in your practice, which will help you identify inefficiencies
Tool as published
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Model-for-improvement worksheet
A worksheet that walks physicians through the process of testing changes for improvement in their practices
Download format: PDF (printer friendly)
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Patient panel size worksheet
A worksheet to help you calculate your current and ideal panel size
Download format: MS Excel
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Patient phone-system survey
A survey that asks patients to evaluate the efficiency of a practice's phone system
Download format: PDF (printer friendly)
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Phone call tracking sheet
A form that tracks and categorizes the frequency of inbound calls by type of call for a period of at least five days
Download format: PDF (printer friendly)
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Practice blueprint
A sample map of the care process within a family practice that can be used to identify areas of improvement in scheduling, patient flow, etc.
Tool as published
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Practice self-assessment
A practice self-assessment based on eight components of military structure
Download format: PDF (printer friendly)
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Practice self-test
A practice self-test designed to give physicians an easy way to evaluate the strengths and weaknesses of their practices
Download format: PDF (printer friendly)
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Practice vitality assessment
A quick practice assessment designed to help you assess how well your practice meets five measurements of a vital practice
Tool as published
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Sample clinical instrument panel
A tool for tracking a practice's performance in key areas and viewing the data on a single page
Download format: MS Excel
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Sample moment-of-truth worksheet
A sample worksheet that helps physicians analyze the moments of truth in their practices, create a service mind-set and identify priorities for improvement
Tool as published
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Staff job satisfaction
A ratings sheet that evaluates a practice's performance in the area of job satisfaction and identifies where improvement is needed
Download format: PDF (printer friendly)
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Telephone traffic study worksheet
A worksheet to tally the number of incoming calls your office receives every hour
Tool as published
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Call distribution spreadsheet
A spreadsheet that can be used to calculate physicians’ call relative value units (RVUs) and distribute call more equitably
Download format: MS Excel
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Patient panel size worksheet
A worksheet to help you calculate your current and ideal panel size
Download format: MS Excel
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Consultation/referral request form
A form to indicate what you need from the consultant and how you wish to be notified about the patient's progress
Download format: PDF (printer friendly), MS Word (modifiable)
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Patient satisfaction survey: Referral process - coordination of care
A survey designed to elicit patient feedback related to the referral process
Download format: PDF (printer friendly)
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Referral form
A simple form physicians can complete to communicate their referral plans internally to the staff member tasked with scheduling patient referrals.
Download format: PDF (printer friendly)
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Referral tracking spreadsheet
A spreadsheet used to track referral requests from initial receipt by the referral coordinator through response from the referral specialist.
Download format: MS Excel
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Sample referral agreement
A sample agreement between clinics intended to reduce waiting times and delays between primary and specialty care by laying out a clear set of guidelines and responsibilities
Download format: MS Word (modifiable)
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Clinical assistant responsibilities in a routine visit
An outline of the duties clinical assistants can be trained to carry out in the team care model
Download format: PDF (printer friendly)
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Employee benefit package summary
A form that lists the total compensation an employee receives each year, including salary, benefits and taxes paid by the employer
Download format: MS Word (modifiable)
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Exit interview questions
A list of questions physicians can ask departing staff members to determine the causes of staff turnover and how to prevent it
Tool as published
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Exit survey sample
A written survey for departing employees intended to determine the cause of staff turnover and how to prevent it
Download format: MS Word (modifiable)
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Job description questionnaire
A questionnaire for staff members to identify their work processes and primary tasks
Download format: PDF (printer friendly)
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Performance record
A quarterly performance record that includes a block of space to record the excellent and poor incidents of an employee's performance each week
Download format: PDF (printer friendly)
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Time line for creating job performance standards
A sample time line for developing and implementing job performance standards
Download format: MS Word (modifiable)
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Work relationship assessment form
A form to assess your practice’s performance in seven areas of work relationships
Download format: PDF (printer friendly)
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