Physician Collaborator Review Template

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Physician Collaborator Review Template

Collaborating Physician Name
N/A

First Name Last Name
Collaborating Physician Email
N/A
Provider Name
N/A

First Name Last Name
Chart Reviews
-- No Fields Available --

Patient Name

Facility Name

Encounter Date

Add Entry
- Patient Name
  N/A
  
  First Name Last Name
- Facility Name
  N/A
- Encounter Date
  N/A
  
  MM-dd-yyyy
- Chief Complaint Completed
  N/A
  
  Yes
  No
- Chief Complaint
  N/A
- HPI Completed
  N/A
  
  Yes
  No
- HPI
  N/A
- History Completed
  N/A
  
  Yes
  No
- History
  N/A
- ROS Completed
  N/A
  
  Yes
  No
- ROS
  N/A
- MSE Completed
  N/A
  
  Yes
  No
- MSE
  N/A
- Diagnosis Completed
  N/A
  
  Yes
  No
- Diagnosis
  N/A
- Plan Completed
  N/A
  
  Yes
  No
- Plan
  N/A
You can continue to add more entries until you have completed 5 chart reviews

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