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Every page on Augustun in one place — product features, medical specialties, EHR integrations, the clinical template library, ICD-10 codes, comparison guides, and blog articles.
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Features
Specialties18 pages
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Head-to-Head Comparisons34
- Augustun vs DeepScribe
- Augustun vs Viva AI
- Augustun vs Twofold
- Augustun vs Skriber
- Augustun vs Heidi Health
- Augustun vs Smith.ai
- Augustun vs Sully.ai
- Augustun vs NudgeAI
- Augustun vs Dentina.ai
- Augustun vs FreedAI
- Augustun vs Commure
- Augustun vs InsightHealth.ai
- Augustun vs MedCalls AI
- Augustun vs Rosie
- Augustun vs Hyro
- Augustun vs Hippocratic AI
- Augustun vs Cognigy
- Augustun vs Infinitus
- Augustun vs MyAI Front Desk
- Augustun vs Lyngo AI
- Augustun vs Zo (ZocDoc)
- Augustun vs OmniMD
- Abridge vs DeepScribe AI
- DeepScribe AI vs Heidi Health
- DeepScribe AI vs Upheal
- Freed AI vs DeepScribe AI
- Freed AI vs Suki AI
- Heidi Health vs Freed AI: Best AI Scribe for Clinicians (2026)
- Heidi Health vs Suki AI
- JotPsych vs Upheal
- JotPsych vs DeepScribe AI
- JotPsych vs Freed AI
- Sunoh AI vs Abridge
- Upheal vs Suki AI
Blog125 pages
- All Articles
- Acupuncture SOAP Notes (With Examples)
- ADHD SOAP Note Example: Documentation for Adults & Children
- AI Scribe for Cardiology: Faster Documentation for Complex Heart Care
- Anxiety SOAP Note Example (GAD, Panic & Social Anxiety)
- Atrial Fibrillation Documentation: AFib Notes, Anticoagulation & Follow-Up
- Augustun + Allscripts EHR Integration: Ambient AI Scribe, ICD-10/CPT Coding & One-Click Write-Back
- Augustun + athenahealth EHR Integration: Ambient AI Scribe, ICD-10/CPT Coding & One-Click Chart Write-Back
- Augustun + Cerner (Oracle Health) EHR Integration: Ambient AI Scribe & One-Click Chart Write-Back
- Augustun + DrChrono Integration: AI Scribe Documentation Inside Your EHR
- Augustun + eClinicalWorks EHR Integration: Ambient AI Scribe, ICD-10/CPT Coding & One-Click Write-Back
- Augustun + Epic EHR Integration: Ambient AI Scribe, ICD-10/CPT Coding & SmartPhrase Write-Back
- Augustun + ModMed (EMA) EHR Integration: Ambient AI Scribe for Specialty Practices
- Augustun + NextGen EHR Integration: Ambient AI Scribe, ICD-10/CPT Coding & One-Click Chart Write-Back
- Augustun + Practice Fusion EHR Integration: Ambient AI Scribe & One-Click Chart Write-Back
- Augustun + SimplePractice Integration: Ambient AI Scribe for Therapists & Behavioral Health
- Augustun + Tebra EHR Integration: Ambient AI Scribe, ICD-10/CPT Coding & One-Click Chart Write-Back
- Augustun EHR Integrations: Epic, athenahealth, Cerner, eClinicalWorks & 6 More Platforms
- Best AI Medical Scribe in Aberdeen (2026): Ambient AI Clinical Documentation for NHS Grampian
- Best AI Medical Scribe in Arizona (2026)
- Best AI Medical Scribe in Belfast (2026)
- Best AI Medical Scribe in Belgium (2026): Ambient AI Clinical Documentation for Huisartsen and Specialists
- Best AI Medical Scribe in Birmingham (2026)
- Best AI Medical Scribe in Bradford (2026)
- Best AI Medical Scribe in Brighton (2026)
- Best AI Medical Scribe in Bristol (2026): Ambient AI for NHS and Academic Clinicians
- Best AI Medical Scribe in California (2026)
- Best AI Medical Scribe in Cambridge (2026): Ambient AI for NHS Clinicians at Addenbrooke's and Beyond
- Best AI Medical Scribe in Cardiff (2026): Ambient AI Documentation for Cardiff and Vale Clinicians
- Best AI Medical Scribe in Colorado (2026)
- Best AI Medical Scribe in Connecticut (2026)
- Best AI Medical Scribe in Coventry (2026)
- Best AI Medical Scribe in Denmark (2026): Ambient AI Clinical Documentation for Danish Doctors
- Best AI Medical Scribe in Derby (2026)
- Best AI Medical Scribe in Dundee (2026): Ambient AI Clinical Documentation for NHS Tayside
- Best AI Medical Scribe in Edinburgh (2026): Ambient AI Documentation for NHS Lothian Clinicians
- Best AI Medical Scribe in England (2026)
- Best AI Medical Scribe in Florida (2026)
- Best AI Medical Scribe in France (2026): Ambient AI for French Clinicians
- Best AI Medical Scribe in Georgia (2026)
- Best AI Medical Scribe in Germany (2026): Ambient AI Clinical Documentation for German Doctors
- Best AI Medical Scribe in Glasgow (2026): Ambient AI Clinical Documentation for NHS Greater Glasgow and Clyde
- Best AI Medical Scribe in Hull (2026)
- Best AI Medical Scribe in Illinois (2026)
- Best AI Medical Scribe in Indiana (2026)
- Best AI Medical Scribe in Ireland (2026): Ambient AI Clinical Documentation for HSE GPs and Specialists
- Best AI Medical Scribe in Italy (2026): Ambient AI Clinical Documentation for MMGs and Specialists
- Best AI Medical Scribe in Leeds (2026): Ambient AI for NHS Clinicians
- Best AI Medical Scribe in Leicester (2026)
- Best AI Medical Scribe in Liverpool (2026)
- Best AI Medical Scribe in London (2026): Ambient Documentation for NHS and Private Clinicians
- Best AI Medical Scribe in Manchester — Top Pick for NHS & Private Clinicians (2026)
- Best AI Medical Scribe in Maryland (2026)
- Best AI Medical Scribe in Massachusetts (2026)
- Best AI Medical Scribe in Michigan (2026)
- Best AI Medical Scribe in Milton Keynes (2026)
- Best AI Medical Scribe in Minnesota (2026)
- Best AI Medical Scribe in Missouri (2026)
- Best AI Medical Scribe in New Jersey (2026)
- Best AI Medical Scribe in New York (2026)
- Best AI Medical Scribe in Newcastle (2026): Ambient AI for NHS Clinicians in the North East
- Best AI Medical Scribe in Newport (2026): Ambient AI Clinical Documentation for Aneurin Bevan Clinicians
- Best AI Medical Scribe in North Carolina (2026)
- Best AI Medical Scribe in North West England (2026): Ambient AI for NHS Clinicians Across Greater Manchester, Merseyside, Lancashire and Cheshire
- Best AI Medical Scribe in Northern Ireland (2026)
- Best AI Medical Scribe in Norwich (2026)
- Best AI Medical Scribe in Nottingham (2026)
- Best AI Medical Scribe in Ohio (2026)
- Best AI Medical Scribe in Oxford (2026): Ambient Documentation for NHS and Academic Clinicians
- Best AI Medical Scribe in Pennsylvania (2026)
- Best AI Medical Scribe in Plymouth (2026)
- Best AI Medical Scribe in Portsmouth (2026)
- Best AI Medical Scribe in Reading (2026)
- Best AI Medical Scribe in Scotland (2026): Ambient AI Clinical Documentation for NHS Clinicians
- Best AI Medical Scribe in Sheffield (2026): Ambient AI for NHS Clinicians
- Best AI Medical Scribe in South Carolina (2026)
- Best AI Medical Scribe in South East England (2026)
- Best AI Medical Scribe in Southampton (2026)
- Best AI Medical Scribe in Spain (2026): Ambient AI Clinical Documentation for SNS and Private Clinicians
- Best AI Medical Scribe in Stoke-on-Trent (2026)
- Best AI Medical Scribe in Swansea (2026): Ambient AI Documentation for Swansea Bay Clinicians
- Best AI Medical Scribe in Sweden (2026): Ambient AI Clinical Documentation for Swedish Läkare
- Best AI Medical Scribe in Switzerland (2026): Ambient AI Clinical Documentation for Swiss Clinicians
- Best AI Medical Scribe in Tennessee (2026)
- Best AI Medical Scribe in Texas (2026)
- Best AI Medical Scribe in the Netherlands (2026): Ambient AI Clinical Documentation for Huisartsen and Specialists
- Best AI Medical Scribe in the UK (2026): The Definitive NHS Guide
- Best AI Medical Scribe in Virginia (2026)
- Best AI Medical Scribe in Wales (2026): Ambient AI Documentation for NHS Wales Clinicians
- Best AI Medical Scribe in Washington (2026)
- Best AI Medical Scribe in Wisconsin (2026)
- Best AI Medical Scribe in Wolverhampton (2026)
- Best AI Scribe for Occupational Therapy (2026)
- Best AI Scribe for Psychiatry: 2026 Comparison & Pricing
- Bipolar Disorder Documentation: SOAP Notes & Medication Management
- Cardiology Consult Notes: Structure, Template & Examples
- Cardiology Documentation: Reduce Charting Time Without Losing Clinical Specificity
- Cardiology SOAP Notes and EHR Integration: A Practical AI Scribe Workflow
- Depression Progress Note: SOAP Examples for MDD Follow-Up
- EHR Integrations for AI Medical Scribes: How Augustun Works Inside Epic, athenahealth & 400+ Systems
- Free BIRP Note Template for Mental Health (2026 Examples)
- Free Cardiac SOAP Note Template + Examples for Cardiologists (2026)
- Free Occupational Therapy SOAP Note Template + 6 OT Examples (2026)
- Free Psychiatric SOAP Note Template (PDF + 2026 Examples)
- How to Write a Psychiatric Intake Note: Guidelines, Template & Example
- How to Write ABA Notes (With Examples)
- How to Write Psychiatry Notes (With Examples)
- How to Write TMS Notes: Documentation Guide for Mental Health Clinicians
- Mental Health Assessment Documentation: Template, Domains & Examples
- Musculoskeletal SOAP Notes (With Examples)
- Occupational Therapy Documentation Template + Cheat Sheet (2026)
- Orthopedic SOAP Notes (With Examples)
- OT Evaluation Note: Templates, Examples & How to Write One
- OT Progress Notes & Discharge Summaries: Templates & Examples
- Pediatric OT SOAP Note Template + Examples (SPD, ASD, DCD, 2026)
- Pediatric SOAP Notes (With Examples & Template)
- Psychiatric Discharge Summary: Template & Examples
- Psychiatric Medication Management Note: Template & Compliance Guide
- Psychiatric Nursing Notes (With Examples)
- PTSD SOAP Note Example: Trauma-Focused Psychiatric Documentation
- School-Based OT Documentation: IEP Notes, DAP Notes & Examples
- SOAP Notes in Physiotherapy (With Examples)
- Substance Use Disorder Documentation: SOAP Notes & MAT Progress Notes
- The 10 Best AI Scribes (2026): Reviews, Pricing & Feature Comparison
- Trauma SOAP Notes (With Examples)
Template Library2,319 pages
Clinical Note1,696
- 12-Lead ECG Acquisition/Interpretation Note (EMS)
- Abdominoplasty Operative Note
- Abnormal CBC Evaluation Note
- Abnormal Liver Enzymes Workup Note
- Abnormal Uterine Bleeding Evaluation Note
- Acne Management Note
- Active Rehabilitation Exercise Session Note
- Actively Dying or End-of-Life Care Note
- Activity Therapy Note (Partial Hospitalization Program)
- Acupuncture Re-evaluation/Progress Update Note
- Acupuncture Session Note (Chronic Low Back Pain, Medicare)
- Acupuncture SOAP Note
- Acupuncture/Dry Needling Treatment Procedure Note
- Acute Care Cross-Cover/Significant Event Note
- Acute Care Discharge Summary (Adult)
- Acute Care ED Encounter Note (Admit/Transfer)
- Acute Care Transfer Note (Unit-to-Unit/Interfacility)
- Acute Care Visit Note (Family Medicine)
- Acute Intermittent Hemodialysis Treatment Note (Pediatric)
- Acute Limb Ischemia Thrombectomy/Embolectomy Operative Note
- Acute Pain Service Consult Note
- Acute Pain Service Daily Progress Note
- Acute Sick Visit Note (Outpatient)
- Acute Sports Injury Visit Note
- Acute Stroke Alert Note (ED/Inpatient)
- Acute Workplace Chemical Exposure Evaluation Note
- Adaptive Recreation Equipment Assessment/Recommendation
- Adaptive Sports/Physical Activity Session Note (Recreational Therapy)
- Addiction Medicine Consultation Note (Inpatient)
- Addiction Medicine Initial Evaluation (Biopsychosocial & Diagnostic)
- ADHD Diagnostic Evaluation Note
- ADHD Medication Initiation/Titration Note
- ADHD Medication Management Follow-Up Note
- Adjustable Gastric Band Adjustment Procedure Note
- Admission History & Physical (Neurosurgery)
- Admission History & Physical (Vascular Surgery)
- Adolescent Confidential Visit Note (HEADSSS)
- Adolescent Preventive Visit Note
- Adult Acute-Care Hospital Admission History & Physical (Inpatient/Observation)
- Adult Annual Preventive Visit (Physical) Note
- Adult Inpatient/Observation Daily Progress Note (Problem-Oriented)
- Adult Malnutrition Assessment & Diagnosis Note (AND/ASPEN Criteria)
- Adult Psychiatric Diagnostic Evaluation
- Advance Beneficiary Notice (ABN) Noncovered Service Discussion Note
- Advance Care Planning Discussion Note
- Advance Care Planning Note
- Adverse Drug Reaction/Allergy Assessment Note
- Adverse Event/Complication Note (Acupuncture and Adjunct Therapies)
- Adverse Event/Incident Note (Acupuncture)
- Adverse Event/Incident Note (Reiki)
- Adverse Event/Incident Note (Yoga Therapy)
- Adverse Event/Safety Incident Note (Hypnosis)
- Adverse Event/Toxicity Assessment Note (Pediatric Oncology)
- Adverse Reaction/Incident Note (Essential Oil Exposure)
- Aeromedical Disposition Note (Fit for Flight/Duty)
- Aeromedical Hypertension Evaluation Note
- Aeromedical Medication Compatibility Review Note
- Aeromedical Mental Health Evaluation Summary (SSRI/Psych History)
- Aerospace Medicine Clinic SOAP Note
- Aesthetic Procedure Complication Visit Note
- After Visit Patient Summary
- Agnikarma Procedure Note
- Airway Clearance Therapy Procedure Note
- Airway Management Procedure Note
- AKI Consultation Note (Nephrology)
- AKI Documentation and Follow-Up Plan (Pediatric)
- Alcohol-Associated Liver Disease Visit Note
- Allergen Immunotherapy Injection Procedure Note (SCIT)
- Allergy and Immunology Inpatient Consultation Note
- Allergy and Immunology New Patient Consultation Note
- Allergy and Immunology Progress Note
- Allergy Evaluation and Treatment Plan Note (Naturopathic Medicine)
- AMD Follow-Up Note (Anti-VEGF/OCT)
- Amputation Operative Note (Minor/Major)
- Anaphylaxis Evaluation Note
- Anesthesia Addendum (Intraoperative Event/Complication)
- Anesthesia Intraoperative Record (Key Events & Interventions)
- Animal-Assisted Therapy Discharge Summary
- Animal-Assisted Therapy Progress Note (SOAP)
- Ankle-Foot Orthosis/Knee-Ankle-Foot Orthosis Delivery Note (AFO/KAFO)
- Ankle-Foot/Knee-Ankle-Foot Orthosis Evaluation Note (AFO/KAFO)
- Antenatal Neonatology Consultation Note
- Antepartum Problem Visit Note (Pregnancy Complication)
- Anti-Obesity Medication Follow-Up/Titration Note
- Anti-Obesity Medication Initiation Note
- Anti-Obesity Medication Initiation Note
- Anticoagulation Management Note (VTE)
- Anticoagulation Management Note (Warfarin/DOAC)
- Antimicrobial Stewardship Intervention Note
- Antipsychotic Monitoring Note (Metabolic/EPS)
- Apicoectomy/Root-End Surgery Procedure Note
- Appendectomy Operative Note (Laparoscopic/Open)
- Aquatic Gait/Balance Training Session Note
- Aquatic Session Incident/Adverse Event Note
- Aquatic Therapy Daily Treatment Note (PT/OT)
- Aquatic Therapy Discharge Summary (PT/OT)
- Aquatic Therapy Group Session Note
- Aquatic Therapy Initial Evaluation (PT/OT)
- Aquatic Therapy Re-evaluation/Progress Report (PT/OT)
- Aromatherapy Intervention Note (Diffusion/Environmental Use)
- Aromatherapy Procedure Note (Inhalation)
- Aromatherapy Procedure Note (Topical Application)
- Aromatherapy Session Note (SOAP)
- Arterial Line Placement Procedure Note
- Arterial Ulcer/Critical Limb Ischemia Evaluation Note
- Artificial Airway Suctioning Procedure Note
- Artwork Documentation & Handling Addendum (Art Therapy)
- Asian Bodywork Therapy Procedure Note (Tuina/Acupressure)
- Asthma Control Assessment & Management Plan (Pediatric)
- Asthma Evaluation/Management Note (Allergy Clinic)
- Asthma Follow-Up Note (with Action Plan)
- Asynchronous Patient Message or E-Visit Note
- Athlete Mental Health Screening Note (SMHAT-1 or Other Instruments)
- Athletic Therapy Initial Evaluation (Musculoskeletal)
- Athletic Therapy Re-Evaluation/Progress Report
- Athletic Therapy Treatment/Progress Note (SOAP)
- Atopic Dermatitis Management Note
- Atrial Fibrillation/Flutter Management Note
- Audiology Follow-Up Note (Hearing Loss Management)
- Augmentative and Alternative Communication Evaluation Report (Speech-Generating Device)
- Auricular Therapy (Ear Seeds/Needles) Procedure Note
- Autism Diagnostic Evaluation Note (Developmental-Behavioral Pediatrics)
- Aviation Mishap Medical Summary (Safety Review)
- Ayurveda Follow-Up Reassessment Note
- Ayurveda Initial Consultation Note (Prakriti/Vikriti Assessment)
- Ayurveda Inpatient Admission Note (H&P)
- Ayurveda Inpatient Discharge Summary
- Ayurveda Outpatient Progress Note
- Back-Table Allograft Preparation Procedure Note
- Bacteremia Evaluation Note
- Balance & Falls Risk Evaluation (Physical Therapy)
- Bariatric Medicine Initial Consultation Note
- Bariatric Surgery Discharge Summary
- Bariatric Surgery Inpatient Daily Progress Note
- Bariatric Surgery Longitudinal Follow-Up Note
- Bariatric Surgery Nutrition Evaluation (Pre-Op)
- Bariatric Surgery Nutrition Follow-Up (Post-Op)
- Bariatric Surgery Post-Op Clinic Follow-Up Note (Early)
- Bariatric Surgery Preoperative Medical Evaluation/Clearance Note
- Bariatric Surgery Psychosocial Evaluation Report
- Barotrauma, Hypoxia, or Decompression-Related Illness Evaluation Note
- Basti Procedure Note (Anuvasana/Niruha)
- Bedside Procedure Note (Pediatric Surgery)
- Behavioral Health & Eating Pattern Screening Note (Obesity Care)
- Behavioral Health Diagnostic Evaluation or Biopsychosocial Intake
- Behavioral Health Discharge Summary
- Behavioral Health Integration Monthly Summary (General BHI)
- Behavioral Medicine Consultation Note (Inpatient/Outpatient)
- Bereavement Follow-Up Contact Note (Hospice/Community)
- Biofeedback Modality Setup/Calibration Note
- Biofeedback Therapy Discharge Summary
- Biofeedback Therapy Initial Evaluation Note
- Biofeedback Therapy Progress Report (10-Visit/Recertification)
- Biofeedback Therapy Session Note
- Biologic Infusion Procedure Note
- Biologic Therapy Follow-Up Note (Asthma, Atopic Dermatitis, or Urticaria)
- Biopsychosocial Intake Assessment (Child/Adolescent)
- Biostimulatory Filler Procedure Note (Non-HA Fillers)
- BIRP Note (Therapy)
- Bladder Cancer Surveillance Note
- Blepharoplasty Operative Note
- Blood Gas Sampling Procedure Note (Arterial/Capillary)
- Blood Product Transfusion Procedure Note (Pediatric Oncology)
- Bloodborne Pathogen Exposure Evaluation Note (Needlestick/Body Fluid)
- Bone Grafting/Sinus Lift Operative Note
- Bone Marrow Aspiration/Biopsy Procedure Note
- Bone Marrow Biopsy Results Review Note
- Bowel Resection and Anastomosis Operative Note (Pediatric)
- Breast Augmentation Operative Note
- Breast Implant Removal/Exchange Operative Note
- Breast Lumpectomy and Sentinel Lymph Node Biopsy Operative Note
- Breast Reconstruction Operative Note
- Brief Operative Note
- Bronchopulmonary Dysplasia Follow-Up Note
- Bronchoscopy Procedure Note (ICU)
- Buprenorphine Induction Note (Office-Based or Home Induction)
- CAKUT/Abnormal Renal Imaging Follow-Up Note (Pediatrics)
- Cancer Treatment Summary (End of Treatment)
- Cardiac Catheterization Procedure Note (Diagnostic)
- Cardiac Catheterization Procedure Note (Interventional)
- Cardiology Admission History & Physical
- Cardiology Consultation Note (Outpatient)
- Cardiology Discharge Summary
- Cardiology Inpatient Consultation Note
- Cardiology Inpatient Progress Note
- Cardiology SOAP Note
- Cardiometabolic Risk Nutrition Therapy Note
- Care Coordination Note (Coach, Athletic Trainer, or Team Physician)
- Care Coordination/Case Management Note
- Care Coordination/Case Management Note (Pediatric Psychology)
- Caregiver Consultation Note (Play Therapy)
- Caregiver Education & Safety Note (Hospice)
- Caregiver/Handler Education Note (Equine Therapy)
- Carotid Endarterectomy Operative Note
- Carotid Stenosis Evaluation Note
- Carotid Stenting Procedure Note (CAS/TCAR)
- Carpal Tunnel Injection Procedure Note
- Carpal Tunnel/Trigger Finger Release Operative Report
- Carrier Screening Counseling Note (Preconception/Reproductive)
- Case Conference/Second-Opinion Request (Homeopathy)
- Case Conference/Supervision Note (Yoga Therapy)
- Case Management Initial Assessment
- Cataract Evaluation & IOL Planning Note
- Cataract Surgery Operative Note (Phacoemulsification/IOL)
- CBT Case Conceptualization (Cognitive Model)
- CBT for Chronic Pain Session Note (SOAP)
- CBT for Insomnia (CBT-I) Session Note
- CBT Intake Assessment (Adult)
- CBT Session Progress Note (DAP)
- CBT Session Progress Note (SOAP)
- CCM Enrollment/Consent Note
- Celiac Disease Note (New Diagnosis)
- Central Venous Access Device Assessment Note (Pediatric Oncology)
- Central Venous Catheter or Port Placement Operative Note
- Central Venous Catheter/Port Removal Operative Note
- Cerebral Palsy/Spasticity Management Note
- Cerumen Removal Procedure Note
- Cesarean Delivery Operative Note
- Chair Massage Encounter Note (On-site Event)
- Chair Reiki Session Note (Brief)
- Chemical Peel Procedure Note
- Chemotherapy Administration/Infusion Note (Pediatric Oncology)
- Chemotherapy Consent/Assent Discussion Note (Pediatric Oncology)
- Chemotherapy Day-of-Treatment Assessment Note (Pediatric Oncology)
- Chest Pain or Acute Coronary Syndrome Evaluation Note
- Chest Tube (Tube Thoracostomy) Procedure Note
- Child & Adolescent Psychiatric Diagnostic Evaluation Note
- Child & Adolescent Psychiatry Follow-Up Progress Note (E/M with Psychotherapy)
- Child & Adolescent Psychiatry Follow-Up Progress Note (Medication Management)
- Chiropractic Discharge or Transition of Care Summary
- Chiropractic Initial Evaluation Note (New Patient)
- Chiropractic Re-Examination/Progress Evaluation Note
- Chiropractic SOAP Note (Follow-Up Visit)
- Chiropractic Spinal Manipulative Treatment Procedure Note
- Chronic Care Management (CCM) Monthly Note
- Chronic Cough Evaluation Note (Pediatric Algorithm)
- Chronic Disease Follow-Up Note (Adult, Internal Medicine)
- Chronic Disease Follow-Up Note (Family Medicine)
- Chronic Disease Follow-Up Note (Multi-Problem)
- Chronic Disease Recheck Note
- Chronic Hepatitis B Management Note
- Chronic Kidney Disease Medical Nutrition Therapy Note
- Chronic Kidney Disease Nutrition Therapy Note
- Chronic Pain Follow-Up Visit Note (In-Person/Telehealth)
- Chronic Pain Psychology Evaluation Note
- Chronic Rhinitis Evaluation Note (Allergy Clinic)
- Chronic Venous Disease Evaluation Note (Varicose Veins)
- Chronic/Functional Digestive Symptoms Evaluation Note
- CIED Implantation Operative Note (Pacemaker/ICD/CRT)
- Cirrhosis Management Note (Decompensated)
- CKD Follow-up Note (Nephrology)
- CKD Initial Evaluation Note (Nephrology)
- Clear Aligner Delivery Note
- Client Communication Note (Phone, Email, or Portal)
- Clinical Photography Documentation Note
- Clinical Swallow Evaluation Note (Bedside)
- Clinical Trial Enrollment Note (Pediatric Oncology)
- Clinical Trial Informed Consent Discussion Note
- Clinical Trial Screening/Enrollment Note
- Closed Reduction/Splinting/Casting Procedure Note
- Clostridioides difficile Infection Management Note
- CLTI Limb-Salvage Evaluation Note (WIfI/Objective Ischemia)
- Cochlear Implant Programming/Mapping Procedure Note
- Cognitive Assessment & Care Plan Note
- Cognitive Rehabilitation Treatment Note
- Cognitive Stimulation/Reality Orientation Group Note (Recreational Therapy)
- Cognitive-Communication Evaluation Report (Adult)
- Colectomy Operative Note (Segmental)
- Collateral Contact Note (SUD)
- Collateral Contact/Care Coordination Note (Behavioral Health & Therapy Services)
- Collateral Interview Note (Forensic)
- Colonoscopy Surveillance Recommendation Note
- Colposcopy Procedure Note (With/Without Cervical Biopsy/ECC)
- Community Health Integration Monthly Note (CHI)
- Community Outing/Community Reintegration Note (Recreational Therapy)
- Complementary Medicine Product Adverse Event/Safety Incident Note
- Complementary/Integrative Therapy Discharge Summary (Completion of Care)
- Complex Chronic Care Management Monthly Note
- Comprehensive Geriatric Assessment Note
- Comprehensive Medication Management Note (Follow-Up)
- Comprehensive Medication Management Note (Initial Assessment)
- Comprehensive Oral Evaluation Note (New Patient)
- Comprehensive Postpartum Follow-Up Visit Note
- Compression Wrap Application Procedure Note (Multilayer)
- Concussion Clinic Note (Return-to-Learn/Return-to-Play)
- Concussion Evaluation and Management Note
- Concussion Follow-Up & RTL/RTS Progress Note
- Congenital Adrenal Hyperplasia Follow-Up Note
- Conjoint Family/Couples Psychotherapy Progress Note
- Constipation/Encopresis Care Plan
- Consult Note (Dance/Movement Therapy)
- Consultation Note (Herbal Medicine, Requested Opinion)
- Consultation Note (Sports Medicine/Orthopedics Referral)
- Consultation-Liaison Psychiatry Consult Note
- Consultation-Liaison Psychiatry Consult Note (Pediatric Inpatient)
- Continuous Glucose Monitor (CGM) Initiation/Placement and Training Procedure Note
- Continuous Home Care Shift Note (CHC)
- Contraception Counseling Note (Shared Decision-Making)
- Contraceptive Implant Insertion/Removal Procedure Note
- Contrast Bath Treatment Note (Upper/Lower Extremity)
- Contrast Reaction Note (Imaging)
- Cosmetic Neuromodulator (Botulinum Toxin) Injection Procedure Note
- Counseling Session Note (School Setting)
- Couples Psychotherapy Note
- Creative Arts Therapy Discharge Summary
- Crisis Evaluation Note (Child/Adolescent)
- Crisis Intervention Note (Substance Use Disorder)
- Crisis Psychiatry Evaluation Note (ED/Urgent)
- Crisis Psychotherapy/Crisis Intervention Note
- Crisis Psychotherapy/Intervention Note
- Crisis Response Note (Student)
- Critical Care Note (Time-Based)
- Critical Care Time Attestation
- Crown Delivery/Cementation Procedure Note
- Crown Preparation Procedure Note
- CRRT Initiation/Management Note
- CRRT Management Note (Pediatrics)
- Cryotherapy Procedure Note (Benign Lesions)
- Cryotherapy Procedure Note (Benign/Premalignant Lesion)
- Cryotherapy Procedure Note (Premalignant Lesions)
- Cupping/Gua Sha Therapy Procedure Note
- Curettage and Electrodesiccation Procedure Note
- Custom Foot Orthoses Evaluation & Casting Note
- Custom Foot Orthoses Evaluation/Delivery Note
- Cutaneous Reconstruction Operative Note (Flap/Graft)
- Cystic Fibrosis Multidisciplinary Clinic Note
- Dance/Movement Therapy Session Note (SOAP, In-Person/Telehealth)
- DAP Note (Art Therapy)
- DAP Note (Play Therapy Session)
- DAP Note (Therapy)
- Death Pronouncement Note
- Death/Pronouncement Note (Hospice)
- Debonding/Appliance Removal Procedure Note
- Deceased Donor Multi-Organ Procurement Operative Note
- Decision-Making Capacity Evaluation Report (Older Adult)
- Delirium Evaluation Note (Acute Mental Status Change)
- Dementia Follow-Up & Caregiver Support Note
- Dementia Reminiscence Music Therapy Group Note
- Dental Encounter Note (SOAP)
- Dental Implant Placement Operative Note
- Dental Prophylaxis/Extractions Procedure Note
- Denture Delivery/Adjustment Procedure Note
- Dermal Filler Injection Procedure Note
- Dermatology Clinic Note (New Patient)
- Dermatology Clinic SOAP Note
- Dermatology/Allergy Visit Note
- Developmental-Behavioral Pediatrics Behavioral Concerns Consultation Note (Disruptive Behavior/Emotional Dysregulation)
- Developmental-Behavioral Pediatrics Consultation Note
- Developmental-Behavioral Pediatrics Diagnostic Feedback Note
- Developmental-Behavioral Pediatrics Follow-Up Note
- Device Interrogation Follow-Up Note (Pacemaker/ICD)
- Diabetes Annual Comprehensive Review Note
- Diabetes Management Note (Outpatient)
- Diabetes Medical Nutrition Therapy (MNT) Note
- Diabetes Prevention Program Session Note (MDPP)
- Diabetic Foot Ulcer Evaluation/Follow-Up Note
- Diabetic Retinopathy Evaluation Note
- Diagnostic Assessment Note (Marriage and Family Therapy)
- Diagnostic Evaluation Note (Older Adult)
- Diagnostic Intake Evaluation (Pediatric Psychology)
- Diagnostic Nasal Endoscopy Procedure Note
- Dialysis Access Creation Operative Note (AV Fistula/AV Graft)
- Dialysis Access Intervention Procedure Note (Fistulogram/Angioplasty/Thrombectomy)
- Dietitian Nutrition Care Process Note (ADIME)
- Difficult Airway Management Procedure Note
- Dilation and Curettage Procedure Note (Early Pregnancy Loss)
- Direct Dictation
- Direct Restoration Procedure Note (Filling)
- Discharge Against Medical Advice (AMA) Note
- Discharge Antibiotic Plan & Transition-of-Care Note
- Discharge Medication Counseling Note
- Discharge Note
- Discharge Nursing Note (Instructions & Readiness)
- Discharge Planning Note (Hospital Case Management)
- Discharge Summary (Athletic Therapy Rehabilitation)
- Discharge Summary (Congenital Heart Disease)
- Discharge Summary (ENT Surgery)
- Discharge Summary (Hypnotherapy Course)
- Discharge Summary (Myofunctional Therapy)
- Discharge Summary (Neurosurgery)
- Discharge Summary (OMFS)
- Discharge Summary (Pediatric Oncology)
- Discharge Summary (Surgery)
- Discharge Summary (Vascular Surgery)
- Discharge Summary (Withdrawal Management/SUD Program)
- Discharge/Termination Summary (Behavioral Health in Medical Setting)
- Discharge/Termination Summary (Pediatric Psychology)
- Discharge/Termination Summary (Play Therapy)
- Discharge/Termination Summary (Psychotherapy, Older Adult)
- Discharge/Termination Summary (Sports Psychology)
- Distance Reiki Session Note
- Dix-Hallpike and Canalith Repositioning Maneuver Procedure Note
- Dizziness/Vertigo Evaluation Note
- DMARD Monitoring Note (Lab Review & Safety)
- DMARD/Biologic Initiation Note (Screening & Counseling)
- DOT/CDL Medical Exam Note (FMCSA)
- Drain Placement/Exchange Procedure Note
- Drama Therapy Progress Note (DAP)
- Drug Challenge Procedure Note
- Drug Information Consult Response Note
- Drug/Alcohol Test Collection Note (DOT/Non-DOT)
- Dry Eye Disease Evaluation Note
- Durable Medical Equipment Dispensing Note (Crutches, Brace, or Support)
- E/M/Psychotherapy Combined Visit Note
- East Asian Herbal Medicine Prescription Note (Formula Initiation/Modification)
- ED Encounter Note (Treat-and-Release)
- Electrical Cardioversion Procedure Note (± Transcutaneous Pacing)
- Electroacupuncture Procedure Note
- Electrophysiology Study/Ablation Procedure Note
- Emergency Department Encounter Note
- Emergency Department Encounter Note (Student)
- Emergency Department Observation Admission Note
- Emergency Department Observation Discharge Summary
- Emergency Department Observation Progress Note
- Emergency Department Procedural Sedation Note
- Emergency Department Psychiatry Evaluation (Pediatric)
- Emergency Department Reassessment/Progress Note
- Emergency/Urgent Care Encounter Note
- EMS Behavioral Health Crisis/Restraints & Sedation Note
- EMS ePCR Addendum/Late Entry
- EMS Opioid Overdose/Naloxone Administration Note
- EMS Patient Care Report (911 Response)
- EMS Patient Care Report (Interfacility Transfer)
- EMS QA/QI Case Review Summary
- EMS Suspected Stroke/TIA Activation Note
- EMS Transfer of Care/Handoff Note (Emergency Department)
- EMS Trauma Patient Care Report
- End-of-Therapy Treatment Summary (Pediatric Oncology)
- Endocrine Stimulation Test Procedure Note (ACTH/GH/GnRH)
- Endocrinology Consultation Note (Inpatient)
- Endocrinology New Patient Consultation Note
- Endocrinology Outpatient Progress Note (SOAP)
- Endodontic Consultation Note (Referred Tooth Evaluation)
- Endodontic Emergency Visit Note (Pain/Swelling)
- Endodontic Follow-Up Note (Post-Op/Healing Evaluation)
- Endodontics SOAP Note
- Endometrial Biopsy Procedure Note
- Endoscopic Sleeve Gastroplasty Procedure Note
- Endoscopy Adverse Event Note
- Endoscopy Consultation Note
- Endoscopy Post-Procedure Recovery/Discharge Note
- Endoscopy Pre-Procedure Assessment & Consent Note
- Endoscopy Pre-Procedure Assessment Note
- Endotracheal Intubation Procedure Note
- Endotracheal Intubation Procedure Note (Neonate)
- Endovascular Intervention Procedure Note (Lower-Extremity PAD)
- Endovenous Ablation/Phlebectomy Procedure Note
- Enteral Nutrition Support Consultation Note (Inpatient)
- Environmental Exposure Assessment Note (Functional Medicine)
- Epidural Steroid Injection Procedure Note
- Epilepsy Follow-Up Clinic Note
- Epistaxis Control Procedure Note
- Equine Therapy Initial Evaluation (OT/PT/SLP)
- Equine Therapy Progress Report (10th Visit/30-day)
- Equine Therapy Re-Evaluation Note
- Equine Therapy Session Note (SOAP)
- Equine-Assisted Psychotherapy Intake Assessment
- Equine-Assisted Psychotherapy Session Note (DAP)
- Erectile Dysfunction/Hypogonadism Evaluation Note
- Esophageal Dilation Procedure Note (Endoscopic)
- ESRD Monthly Dialysis Comprehensive Note (MCP)
- Essential Oils Managed as Medication Note (Institutional Policy)
- Euthanasia & Aftercare Note
- Evaluation Note (Weight Regain After Bariatric Surgery)
- EVAR Procedure Note (Infrarenal AAA)
- Excision Procedure Note (Benign Lesion)
- Excision Procedure Note (Malignant Lesion)
- Expert Witness Testimony Preparation Note
- Exposure and Bonding of Impacted Tooth Procedure Note
- Exposure Therapy/ERP Session Note
- Extended-Release Naltrexone Injection Procedure Note
- External Ventricular Drain Placement Procedure Note (Bedside)
- Extraction Procedure Note (Simple/Surgical)
- FAA Airman Medical Certificate Exam Note (Form 8500-8 Support)
- Facelift/Neck Lift Operative Note
- Facet Joint Injection/Medial Branch Block Procedure Note
- Facial Fracture ORIF Operative Note (Mandible/Midface)
- Facial Laceration Repair Procedure Note
- Falls Risk Evaluation & Prevention Plan Note
- Family Medicine Note
- Family Medicine SOAP Note
- Family Meeting Note (Care Planning)
- Family Meeting/Goals of Care Note (Pediatric Oncology)
- Family Psychotherapy Note (Child/Adolescent)
- Family Psychotherapy Note (Play Therapy)
- Family Psychotherapy Session Note (Identified Patient Not Present)
- Family Psychotherapy Session Note (Identified Patient Present)
- Family Session Note (Athlete Support System)
- Family Therapy Progress Note (Pediatric Psychology)
- Family/Caregiver Counseling Note (Rehabilitation)
- Family/Caregiver Session Note (Art Therapy)
- Family/Caregiver Session Note (Dance/Movement Therapy)
- Family/Couples CBT Session Note
- Febrile Neutropenia Evaluation Note (Pediatric Oncology)
- Febrile Neutropenia/Immunocompromised Host Consult Note
- Fetal Cardiology Consultation Note
- First Seizure/New-Onset Seizure Evaluation Note
- First Unprovoked Seizure Evaluation Note
- Fixed Appliance Placement Procedure Note (Bonding/Banding)
- Flexible Bronchoscopy Procedure Note
- Flexible Cystoscopy Procedure Note
- Follow-Up Visit Note (Herbal Medicine)
- Food Allergy Evaluation Note
- Foot/Ankle Injection Procedure Note
- Foot/Ankle Surgery Preoperative H&P
- Foreign Body Removal Procedure Note
- Foreign Body Removal Procedure Note (Corneal/Conjunctival)
- Foreign Body Removal Procedure Note (Ear/Nose)
- Forensic Evaluation Session Note
- Forensic Treatment Progress Note (Correctional/Forensic Hospital)
- Fracture/Sprain Management Note (Foot/Ankle)
- Functional Abdominal Pain/IBS Care Plan Note
- Functional Medicine Follow-Up Visit Note (In-Person or Telehealth)
- Functional Medicine Initial Consultation Note (Comprehensive)
- Functional Nutrition Consultation Note
- Functional Status (ADL/IADL) & Home Safety Assessment Note
- Fundoplication Operative Note (Laparoscopic)
- Gait/Assistive Device Assessment Note
- Gastroenterology Clinic SOAP Note
- Gastroenterology Consultation Note (Inpatient)
- Gastroenterology Inpatient Progress Note
- Gastrointestinal Signs Visit Note (Vomiting/Diarrhea)
- Gastrostomy Tube Placement Operative Note
- General Inpatient Hospice Admission/Progress Note (GIP)
- Genetic Counseling Consult Note (Hybrid)
- Genetic Counseling Consultation Note (Hereditary Cancer Risk Assessment)
- Genetic Counseling Follow-Up Note (Hybrid)
- Genetic Counseling Telehealth Visit Note
- Genetic Medicine Consultation Note
- Genetic Medicine Follow-Up Note
- Genetic Test Consent & Order Note (Germline)
- Genetic Test Ordering & Coordination Note
- Genetic Test Results Disclosure Note
- Genetic Testing Informed Consent/Pre-Test Counseling Note
- Geriatrics SOAP Note
- Geropsychology Psychotherapy Progress Note (SOAP)
- GI Disorder Nutrition Note
- Glaucoma Evaluation Note (New Patient)
- Glaucoma Follow-Up Note
- Global Developmental Delay/Intellectual Disability Evaluation Note
- Glomerulonephritis/Vasculitis Evaluation Note (Pediatric)
- GLP-1/GIP Injection Teaching Note
- Goals of Care/Serious Illness Conversation Note (Oncology)
- Gout Follow-Up Note (Treat-to-Target ULT)
- Grief Counseling Intake Assessment (Adult)
- Grief Counseling Progress Note (Family Session)
- Grief Counseling Progress Note (Group Therapy)
- Grief Counseling SOAP Note (Psychotherapy)
- Ground-Based Equine-Assisted Activity Session Note
- Group CBT Session Note
- Group Counseling Note (School Setting)
- Group Drama Therapy Session Note
- Group Hypnotherapy Session Note
- Group Intensive Behavioral Therapy for Obesity Note
- Group Play Therapy Note
- Group Psychotherapy Note (Athletes)
- Group Psychotherapy Note (Child/Adolescent)
- Group Psychotherapy Note (Older Adult)
- Group Psychotherapy Progress Note
- Group Session Note (Animal-Assisted Therapy)
- Group Session Note (Art Therapy)
- Group Session Note (Dance/Movement Therapy)
- Group Therapy Note (Pain Rehabilitation)
- Group Therapy Progress Note (Pediatric Psychology)
- Group Wellness Education Session Note
- Group Yoga Therapy Class Note (Attendance & Response)
- Growth Hormone Therapy Start Note
- Gut-Directed Hypnotherapy Session Note (IBS)
- Gynecology Consultation Note (Inpatient/ED)
- Gynecology Problem Visit Note (Focused)
- H&P
- H&P Update (Day of Surgery)
- Habit Elimination Program Note (Thumb, Pacifier, or Oral Habits)
- Hand Surgery Operative Note
- Hardware Removal/Implant Exchange Operative Report
- HDR Brachytherapy Written Directive/Procedure Note
- Headache Biofeedback Session Note (Migraine/Tension-Type)
- Headache/Migraine Clinic Note
- Headache/Migraine Clinic Note
- Health & Behavior Assessment Note (Pediatric)
- Health & Behavior Intervention Progress Note (Pediatric)
- Health Behavior Assessment Note (HBAI)
- Health Behavior Assessment Note (HBAI)
- Health Behavior Assessment/Intervention Note (Injury/Pain/Rehab)
- Health Behavior Intervention Note (Group/Family HBAI)
- Health Behavior Intervention Note (Individual)
- Health Behavior Intervention Note (Individual)
- Health Coaching Session Note (Functional Medicine)
- Health Psychology Progress Note (SOAP)
- Healthy Weight Counseling Visit Note (Pediatrics)
- Hearing Aid Evaluation Note
- Hearing Aid Fitting/Dispensing Procedure Note
- Hearing Aid Follow-Up/Adjustment Note
- Hearing Assistive Technology Evaluation Note
- Hearing Conservation Audiogram Review Note
- Heart Failure Follow-Up Note
- Hematology Inpatient Consultation Note
- Hematology Inpatient Progress Note
- Hematology New Patient Consultation Note (Outpatient)
- Hematology Outpatient Clinic Note (SOAP)
- Hematuria Evaluation Note
- Hematuria/Proteinuria Evaluation Note (Pediatric)
- Hemophilia/Inherited Bleeding Disorder Comprehensive Visit Note
- Hepatitis C Treatment Plan
- Hepatology Discharge Summary (Cirrhosis/Chronic Liver Disease)
- Hepatology Initial Consultation Note (Outpatient)
- Hepatology Inpatient Consultation Note
- Hepatology Inpatient Progress Note
- Hepatology SOAP Note
- Herb-Drug Interaction & Safety Screening Note
- Herbal Formula/Prescription Note
- Herbal Medicine SOAP Note
- Hernia Repair Operative Note (Inguinal)
- Hernia Repair Operative Note (Ventral/Incisional)
- High-Flow Nasal Cannula Note
- High-Risk Infant Follow-Up Clinic Note
- High-Risk Prenatal Visit Note
- Hip Fracture Surgery Operative Report (Fixation/Hemiarthroplasty)
- HIPAA Psychotherapy Process Note (Kept Separate from the Medical Record)
- Hippotherapy Safety & Horse Selection Note
- Hippotherapy Treatment Session Note (Mounted Equine Movement)
- HIV Follow-Up Note
- HIV Initial Intake Note
- Home Dialysis Monthly Management Note (PD/Home HD)
- Home Health Care Coordination Note (Physician/Facility/Pharmacy)
- Home Health Medication Reconciliation & MMTA Note
- Home Health Physical Therapy Start-of-Care Evaluation
- Home Health Physical Therapy Visit Note
- Home Health Skilled Nursing Visit Note (OASIS-Driven)
- Home Health Skilled Visit Note (Interdisciplinary)
- Home/Residence Visit Note
- Homeopathy Follow-Up Visit Note (Chronic Care)
- Homeopathy Initial Consultation Note (Constitutional Case-Taking)
- Homeopathy Intake Summary (Patient Questionnaire to HPI)
- Homeopathy Progress Note
- Horticultural Therapy Co-Treatment Note (OT/PT/SLP Collaboration)
- Horticultural Therapy Discharge Summary
- Horticultural Therapy Group Session Note (SOAP)
- Horticultural Therapy Incident/Injury Note
- Horticultural Therapy Initial Evaluation (Clinical)
- Horticultural Therapy Interdisciplinary Care Team Update
- Horticultural Therapy Re-Evaluation/Progress Report
- Horticultural Therapy Session Note (SOAP)
- Hospice Admission Note (Initial and Comprehensive Assessment)
- Hospice Discharge, Revocation, or Transfer Summary
- Hospice Evaluation and Referral Note
- Hospice Face-to-Face Encounter Note for Recertification
- Hospice Interdisciplinary Visit Note (Routine Home Care)
- Hospice Medication Management Note (Comfort Kit/Deprescribing)
- Hospice Recertification Note (Benefit Period)
- Hospital Admission Note
- Hospital Psychosocial Assessment & Discharge Planning Note
- Hubbard Tank Hydrotherapy Treatment Note
- Hyperbaric Oxygen Therapy (HBOT) Daily Treatment Note
- Hypnotherapy Session Note (Chronic Pain)
- Hypnotherapy Session Note (DAP)
- Hypnotherapy Session Note (Menopausal Vasomotor Symptoms)
- Hypnotherapy Session Note (Procedure-Related Anxiety)
- Hypnotherapy Session Note (Smoking Cessation)
- Hypnotherapy Session Note (SOAP)
- Hysterectomy Operative Note
- Hysteroscopy with D&C/Polypectomy Operative Note
- ICU Consult Note (Critical Care Medicine)
- ICU Daily Progress Note (Critical Care Medicine)
- ICU Discharge Summary (Critical Care Medicine)
- ICU Family Meeting/Goals of Care Communication Note
- ICU Transfer Note (ICU-to-Floor/Step-Down)
- ICU Transfer Note (Internal Medicine)
- IEP Goal Progress Report (Speech-Language)
- IEP Meeting Summary (School Psychologist)
- IEP Speech-Language Session Note
- Image-Guided Biopsy/Aspiration Procedure Note
- Imaging Order/Referral (X-ray, MRI, or CT)
- Imaging Review Note (Orthopedic Surgery)
- Immediate Postoperative Note (Neurosurgery)
- Immunization Administration Procedure Note
- Immunization-Only Visit Note
- Immunization/Titer Visit Note (Occupational Medicine)
- In-Center Hemodialysis Rounding Note (Interim Visit)
- Incision & Drainage Procedure Note (Odontogenic Infection)
- Incision and Drainage or Trephination Procedure Note (Endodontic Abscess)
- Independent Interpretation Note (Imaging/Labs)
- Independent Medical Examination (IME) Report
- Indwelling Pleural Catheter (IPC) Procedure Note
- Infectious Disease Inpatient Consultation Note
- Infectious Disease Inpatient Progress Note
- Infectious Disease Outpatient Follow-Up Note
- Infectious Disease SOAP Note
- Inflammatory Bowel Disease Follow-Up Note (Pediatric)
- Informed Consent & Confidentiality Discussion Note (Sports Psychology)
- Informed Consent & Orientation Note (Counseling)
- Informed Consent Discussion Note (Procedure/Treatment)
- Infusion Reaction Acute Event Note
- Ingrown Toenail Procedure Note (Partial Nail Avulsion)
- Inguinal/Umbilical Hernia Repair Operative Note
- Initial Consultation Note (Herbal Medicine)
- Initial Evaluation (Play Therapy)
- Initial Evaluation (Sports Psychology)
- Initial Evaluation Note (Animal-Assisted Therapy)
- Initial Evaluation Note (Art Therapy)
- Initial Evaluation Note (Health Psychology)
- Initial Nutrition Assessment Note (ADIME)
- Initial Prenatal Visit Note (OB Intake)
- Injury Rehabilitation Mental Skills Session Note
- Inpatient Admission H&P (Pediatric Oncology)
- Inpatient Admission Note (Oral and Maxillofacial Surgery)
- Inpatient Bedside Reiki Note (Integrative Therapy)
- Inpatient Behavioral Health Consultation Note (Older Adult)
- Inpatient Behavioral Health Discharge Summary
- Inpatient Complementary Therapy Nursing Note (Aromatherapy)
- Inpatient Consultation Note (General)
- Inpatient Daily Progress Note
- Inpatient Daily Progress Note (Oral and Maxillofacial Surgery)
- Inpatient Daily Progress Note (Pediatric Oncology)
- Inpatient Daily Progress Note (Vascular Surgery)
- Inpatient Dermatology Consult Note
- Inpatient Genetics Consultation Note
- Inpatient Goals of Care/Serious Illness Conversation Note
- Inpatient Medical Unit Note (Art Therapy)
- Inpatient Nutrition Consultation Note (ADIME)
- Inpatient Nutrition Follow-Up Note (ADIME)
- Inpatient Oncology Consultation Note
- Inpatient Oncology Progress Note
- Inpatient Osteopathic Consult Note (OMT)
- Inpatient Pain Consultation Note
- Inpatient Pediatric Psychology Consultation-Liaison Note
- Inpatient Postpartum Lactation Consult Note
- Inpatient Psychiatry Admission H&P
- Inpatient Psychiatry Admission H&P (Child/Adolescent)
- Inpatient Psychiatry Admission Note
- Inpatient Psychiatry Daily Progress Note
- Inpatient Psychiatry Daily Progress Note (Child/Adolescent)
- Inpatient Psychiatry Discharge Summary (Child/Adolescent)
- Inpatient Rapid Response/Code Blue Event Note
- Inpatient Rehabilitation Facility Interdisciplinary Team Conference Note
- Inpatient Rehabilitation Psychology Consult Note
- Inpatient Rehabilitation Psychology Progress Note
- Inpatient Respite Care Admission/Progress Note
- Inpatient Rheumatology Consultation Note
- Inpatient Wound Care Consultation Note
- Inpatient/Acute Care Acupuncture Consult Note
- Insomnia Evaluation (CBT-I Intake)
- Insulin Pump or Automated Insulin Delivery Start Visit Note
- Insulin Pump Start/Training Note
- Insulin Pump/AID Management Note
- Intake Assessment (Dance/Movement Therapy)
- Intake Assessment (Drama Therapy)
- Intake Assessment (Psychotherapy)
- Intake Assessment (Substance Use Disorder, Biopsychosocial)
- Intake Assessment (SUD Biopsychosocial)
- Intake Questionnaire/Records Review Summary (Functional Medicine)
- Integrated Primary Care Behavioral Health Consultation Note (Older Adult)
- Integrated Primary Care Behavioral Health Consultation Note (Pediatric)
- Integrated Primary Care Behavioral Health Warm-Handoff Consultation Note
- Integrative Medicine Comprehensive Initial Consultation Note
- Integrative Medicine Consult Note (Inpatient)
- Integrative Medicine Follow-Up Note (Plan Update)
- Integrative Medicine SOAP Note
- Interactive Complexity Addendum
- Interdisciplinary Care Plan Update Note (Nursing)
- Interdisciplinary Case Conference Note
- Interdisciplinary Co-Treatment Note (Animal-Assisted Therapy)
- Interdisciplinary Group Meeting Note (Hospice IDG)
- Interdisciplinary Team Conference Note (IRF)
- Interdisciplinary Team Update Note (Art Therapy)
- Interdisciplinary Treatment Team Update (Behavioral Health)
- Interfacility Transfer Note (EMTALA Transfer)
- Interfacility Transfer/Acceptance Note (Pediatric Surgery)
- Internal Medicine New Patient Note
- Internal Medicine Note
- Internal Medicine SOAP Note
- Interprofessional Communication Note (Clinical Aromatherapy)
- Interprofessional Coordination Note (Medicare Integral Dental Services)
- Interventional Pain Pre-Procedure Evaluation Note
- Interventional Radiology Consultation Note (Pre-Procedure)
- Interventional Radiology Procedure Note (General)
- Intracoronal Bleaching Procedure Note (Nonvital Bleaching)
- Intracranial Pressure Monitor Placement Procedure Note (Bedside)
- Intragastric Balloon Placement/Removal Procedure Note
- Intralesional Injection Procedure Note (Corticosteroid)
- Intrapartum Labor Progress Note
- Intrathecal Baclofen Pump Refill/Reprogramming Procedure Note
- Intrathecal Drug Delivery Pump Refill/Programming Procedure Note
- Intrathecal Drug Delivery Pump Trial Procedure Note
- Intravesical Therapy Instillation Procedure Note
- Intravitreal Injection Procedure Note
- Involuntary Hospitalization Evaluation Note
- IPL/BBL Photofacial Procedure Note
- IRF Admission History & Physical
- IRF Discharge Summary (Rehab)
- IRF Rehabilitation Physician Progress Note
- Isotretinoin Monitoring Visit Note
- Issues List
- IUD Insertion/Removal Procedure Note
- IV Hydration/Infusion Therapy Procedure Note
- IV Iron Infusion Therapy Note
- IV Therapy/PICC-Midline Care Procedure Note
- Jaw Cyst Enucleation/Marsupialization Operative Note
- Joint Reduction Procedure Note
- Kawasaki Disease Cardiology Follow-Up Note
- Kidney Biopsy Pre-Procedure Note (Pediatric)
- Kidney Biopsy Procedure Note (Pediatrics)
- Kidney Replacement Therapy Education & Modality Choice Note
- Kidney Transplant Evaluation Note (Pediatrics)
- Kidney Transplant Follow-Up Note (Nephrology)
- Kidney Transplant Follow-Up Note (Pediatrics)
- Kidney Transplant Operative Note
- Knee Arthroscopy Operative Report (Meniscectomy/Chondroplasty)
- Knee Orthosis Evaluation Note (Instability Documentation)
- Labor and Delivery Admission History and Physical
- Labor Epidural Analgesia Procedure Note
- Laboratory/Imaging Results Review Note (Naturopathic Medicine)
- Laceration Repair Procedure Note
- Lactation Consultation SOAP Note
- Lactation Counseling Note (Time-Based Billing)
- Lactation Follow-Up SOAP Note
- Lactation Note (Low Milk Supply)
- Laparoscopic Cholecystectomy Operative Note
- Laser Hair Removal Procedure Note
- Laser Peripheral Iridotomy Procedure Note
- Laser Skin Resurfacing Procedure Note
- Laser/Skin Resurfacing Procedure Note
- Latent Tuberculosis Evaluation and Treatment Note
- LDR Prostate Seed Implant Procedure Note
- Learning Difficulties and School Functioning Consultation Note
- LEEP (Cervical Excisional Procedure) Procedure Note
- Left Without Being Seen/Elopement Note
- Lifestyle & Nutrition Counseling Note (Integrative Medicine)
- Lip Augmentation Procedure Note (Injectable Filler)
- Liposuction Operative Note
- Liver Biopsy Procedure Note (Percutaneous)
- Liver Transplant Evaluation Note
- Liver Transplant Operative Note
- Liver Tumor Board Note
- Living Donor Hepatectomy Operative Note
- Living Donor Informed Consent Discussion Note
- Living Donor Nephrectomy Operative Note (Laparoscopic/Robotic)
- Living Donor Post-Op/Follow-Up Clinic Note
- Living Donor Surgical Evaluation Note
- Long-Acting Injectable Antipsychotic Administration Procedure Note
- Long-Term Care Behavioral Health Initial Assessment (SNF/ALF)
- Long-Term Care Behavioral Health Progress Note (SNF/ALF)
- Lower Extremity Bypass Operative Note (Infrainguinal)
- Lower Limb Prosthesis Delivery Note (Definitive)
- Lower-Limb Prosthetic Initial Evaluation (Pre-Prosthetic)
- Lumbar Decompression (With or Without Discectomy) Operative Report
- Lumbar Drain Placement Procedure Note
- Lumbar Puncture Procedure Note
- Lumbar Puncture Procedure Note (Neonate)
- Lumbar Puncture with Intrathecal Chemotherapy Procedure Note
- Lung Cancer Screening Shared Decision-Making Visit Note
- LUTS/BPH Management Note
- Lymphedema Evaluation & Treatment Note
- Maintenance/Retention Visit Note (Myofunctional Therapy)
- Mandated Report or Duty to Protect Documentation Note
- Manifestation Determination Review Summary
- Manual Lymphatic Drainage (MLD) Treatment Note
- Manual Therapy/Manipulation Procedure Note
- Manual Therapy/Massage Treatment Note
- Manual Therapy/Physical Medicine Treatment Note (Naturopathic Medicine)
- Marriage and Family Therapy Session Note (DAP)
- MASLD/MASH Clinic Note
- Mass Removal/Biopsy Procedure Note
- Massage Therapy Discharge Summary
- Massage Therapy Initial Evaluation (SOAP)
- Massage Therapy Re-evaluation/Progress Note
- Massage Therapy Session SOAP Note
- Massive Transfusion Protocol Activation Note
- Mastitis, Engorgement, or Plugged Duct Lactation Note
- Mastopexy/Breast Lift Operative Note
- Measurement-Based Care Symptom Scale Progress Note
- Mechanical Ventilation Initiation/Setup Procedure Note
- Med-Peds Acute Visit Note (Same-Day/Urgent)
- Med-Peds Outpatient SOAP Note
- Medical Aesthetics Consultation & Treatment Plan Note
- Medical Aesthetics Follow-Up/Progress Note
- Medical Decision-Making Capacity Evaluation Note
- Medical Review Officer (MRO) Result Verification Note
- Medical Screening Exam Note (EMTALA)
- Medical Thoracoscopy/Pleuroscopy Procedure Note
- Medical Weight Management Follow-Up Note (Lifestyle and Pharmacotherapy, In-Person or Telehealth)
- Medical-Legal Injury Documentation Note (Assault/IPV)
- Medicare Annual Wellness Visit (AWV) Note
- Medicare Annual Wellness Visit Support Note (HRA Inputs)
- Medicare Chiropractic Initial Visit Note (CMT)
- Medicare Chiropractic Subsequent Visit Note (CMT)
- Medicare Intensive Behavioral Therapy for Obesity Progress Note (Individual)
- Medication & Supplement Reconciliation and Safety Review Note
- Medication Administration Note (PRN, Refusal, or Adverse Reaction)
- Medication Administration Procedure Note (IM/SC Injection)
- Medication Reconciliation Note (Pharmacist)
- Medication Review & Deprescribing Note
- Medicolegal Death Report Intake/Triage Note
- Menopause Management Note
- Mental Health Music Therapy Session Note (Song Discussion/Lyric Analysis)
- Mental Status Exam & Risk Assessment (Behavioral Health)
- Methadone OTP Intake & Care Plan Note
- Methadone OTP Periodic Assessment Note
- Methadone Take-Home Decision Note (OTP)
- Microneedling Procedure Note
- Micronutrient Deficiency Evaluation & Repletion Note (Post-Bariatric)
- Military Flight Physical Note (Initial/Periodic)
- Milk Transfer/Weighted Feed Assessment Note
- Mind-Body Medicine Session Note (Mindfulness/Relaxation Training)
- Minor Office Procedure Note (Skin/Soft Tissue)
- Moderate Sedation Note (Radiology/IR)
- Mohs Micrographic Surgery Operative Note
- Monitored Anesthesia Care (MAC) Sedation Note
- Monoclonal Gammopathy Evaluation Note
- Monthly Dialysis Management Note (ESRD MCP)
- Motion Sickness/Spatial Disorientation Evaluation Note
- MOUD Monitoring & Adherence Risk Mitigation Note
- MOUD/MAT Coordination Note (Counselor)
- Movement Disorders Clinic Note
- Moxibustion Procedure Note
- MTM Comprehensive Medication Review Note (Medicare Part D)
- MTM Targeted Medication Review Note (Medicare Part D)
- Multidisciplinary Team Conference Note (Developmental-Behavioral Pediatrics)
- Multidisciplinary Tumor Board Note
- Multidisciplinary Tumor Board Note (Pediatric Oncology)
- Multiple Sclerosis/Neuroimmunology Follow-Up Note
- Multiple-Family Group Psychotherapy Note
- Musculoskeletal EMG Biofeedback Session Note (Muscle Re-Education/Spasm)
- Music Therapy Consult Note
- Music Therapy Discharge Summary
- Music Therapy Group Session Note
- Music Therapy Initial Assessment
- Music Therapy Progress Report (Re-evaluation)
- Music Therapy Session Note (SOAP, In-Person/Telehealth)
- Myofunctional Therapy Treatment Session Note (SOAP)
- Nail Matrixectomy Procedure Note
- Nasya Procedure Note
- Native Kidney Biopsy Procedure Note
- Naturopathic Follow-Up Progress Note (SOAP, In-Person or Telehealth)
- Naturopathic New Patient Comprehensive Intake Note
- Nebulized Bronchodilator Treatment Procedure Note
- Negative Pressure Wound Therapy (NPWT) Dressing Change Procedure Note
- Negative-Pressure Wound Therapy (NPWT) Initiation Note
- Neonatal Sepsis Risk Evaluation Note (Early-Onset Sepsis)
- Neonatology Consultation Note (Inpatient)
- Nephrolithiasis Evaluation & Management Note
- Nephrolithiasis/Nephrocalcinosis Clinic Note (Pediatric)
- Nephrology Inpatient Consultation Note
- Nephrology Inpatient Progress Note
- Nephrology Progress Note (SOAP)
- Nephrotic Syndrome Visit Note (Pediatrics)
- Neurobehavioral Status Examination Note/Report
- Neurocognitive Screening Note (MoCA/MMSE)
- Neurodevelopmental Evaluation Note (Developmental Delay/Regression)
- Neurologic Music Therapy Session Note (RAS, PSE, or TIMP)
- Neurology Admission H&P (Inpatient)
- Neurology Discharge Summary
- Neurology Inpatient Consultation Note
- Neurology Inpatient Progress Note
- Neurology New Patient Consultation Note (Outpatient)
- Neurology Outpatient SOAP Note
- Neurology Telehealth Follow-Up Note
- Neuromuscular Weakness Evaluation Note
- Neuropsychological Screening Note (Rehabilitation)
- Neuropsychological Testing Session Note
- Neuropsychology Intake/Clinical Interview Note
- Neurostimulator Programming Note (DBS/VNS)
- Neurosurgery Consultation Note (Outpatient)
- Neurosurgery Daily Progress Note (Inpatient)
- Neurosurgery Follow-Up Note (Outpatient)
- Neurosurgery Inpatient Consultation Note
- Neurosurgery SOAP Note
- New Patient Evaluation (Osteopathic/OMM)
- New Patient Intake Assessment (Adult, Internal Medicine)
- Newborn Admission Note (Hospital)
- Newborn Daily Progress Note
- Newborn Discharge Summary
- NICU Admission Note (Neonatology H&P)
- NICU Daily Progress Note (Systems-Based)
- NICU Discharge Summary
- NICU Lactation Consultation Note
- NICU Significant Event Note (Acute Change)
- NICU Transfer Summary (Interfacility Transfer/Back-Transport)
- Nipple Pain/Nipple Trauma Lactation Note
- No-Show/Late Cancellation Note (Behavioral Health)
- Non-Fatal Strangulation Medical Forensic Exam Note
- Non-Tunneled Central Venous Catheter/Introducer Placement Procedure Note
- Noninvasive Fat Reduction/Body Contouring Procedure Note
- Noninvasive Ventilation Note (CPAP/BiPAP)
- Nonsurgical Root Canal Therapy Procedure Note
- Nonsurgical Skin Tightening Procedure Note
- Nursing Facility Admission Note
- Nursing Facility Discharge-Day Management Note
- Nursing Facility Subsequent Visit Note
- Nursing Focused Assessment Note (Change in Condition)
- Nursing Handoff Note (SBAR)
- Nursing Progress Note (Assessment–Intervention–Evaluation)
- Nutrition & Lifestyle Counseling Note (Traditional Chinese Medicine)
- Nutrition Counseling Note (Medical Weight Management)
- Nutrition Education Group Visit Note
- Nutrition Support Progress Note (Parenteral Nutrition/TPN)
- Nutrition Therapy Note (ADIME)
- Nutrition-Focused Physical Exam (NFPE) Findings Note
- OASIS Assessment
- OASIS Discharge Assessment/Discharge Summary (Home Health)
- OB/GYN Ambulatory SOAP Note
- Obesity Medicine Initial Consultation Note
- Obesity/Weight Management Medical Nutrition Therapy Note
- Obstetric (Delivery/Postpartum) Discharge Summary
- Obstetric Triage Evaluation Note
- Occipital Nerve Block Procedure Note
- Occupational Medicine Clinic SOAP Note
- Occupational Medicine Visit Note (Work-Related Injury/Illness)
- Occupational Therapy Acute Care Initial Evaluation
- Occupational Therapy Daily Treatment Note (SOAP)
- Occupational Therapy Discharge Summary (Episode of Care)
- Occupational Therapy Home Health Visit Note
- Occupational Therapy Inpatient Treatment Note
- Occupational Therapy Progress Report (10th Visit/30-Day)
- Occupational Therapy Re-Evaluation
- Offloading Device Application Procedure Note (Total Contact Cast/Walker)
- OMT Follow-Up Visit Note (Planned Treatment, No Separate E/M)
- OMT Procedure Note
- Oncology Clinic Note (SOAP)
- Oncology Discharge Summary
- Oncology Infusion Reiki Note
- Oncology New Patient Consultation Note
- Oncology Surveillance Follow-Up Note (Post-Treatment)
- Oncology Telephone/Portal Encounter Note
- Oncology Treatment Cycle Visit Note (Pre-Infusion Clearance)
- Oncology Urgent Symptom/Toxicity Visit Note
- OPAT Monitoring Note (Weekly)
- Operative Note
- Operative Note (Endoscopic Sinus Surgery)
- Operative Note (Exploratory Laparotomy/Damage Control Laparotomy)
- Operative Note (Foot/Ankle Surgery)
- Operative Note (Myringotomy/Tympanostomy Tube Placement)
- Operative Note (Open Vascular Surgery)
- Operative Note (Plastic Surgery - General)
- Operative Note (Septoplasty/Turbinate Reduction)
- Operative Note (Trauma Thoracotomy/Resuscitative Thoracotomy)
- Operative Report (Anterior Cervical Discectomy and Fusion)
- Operative Report (Burr Hole Drainage of Chronic Subdural Hematoma)
- Operative Report (Craniotomy for Tumor Resection)
- Operative Report (Craniotomy/Craniectomy for Hematoma Evacuation)
- Operative Report (Lumbar Discectomy/Microdiscectomy)
- Operative Report (Lumbar Interbody Fusion)
- Operative Report (Orthopedic Surgery)
- Operative Report (Posterior Cervical Decompression/Fusion)
- Operative Report (Posterior Lumbar Fusion/Instrumentation)
- Operative Report (Ventriculoperitoneal Shunt Placement/Revision)
- Operative Vaginal Delivery Procedure Note (Vacuum/Forceps)
- Ophthalmology Consultation Note (Inpatient/ED)
- Ophthalmology Office Visit Note (Comprehensive)
- Ophthalmology Postoperative Follow-up Note (Retina/Vitreoretinal)
- Opioid Therapy Management Note
- Opioid Use Disorder Medication-Assisted Treatment Follow-Up Note
- Optometry Cataract Evaluation & Referral Note
- Optometry Cataract Post-Operative Follow-Up Note (Co-management)
- Optometry Comprehensive Eye & Vision Examination Note (Adult)
- Optometry Contact Lens Evaluation Note (New Fit/Refit)
- Optometry Contact Lens Follow-Up Note
- Optometry Diabetic Eye Examination Note
- Optometry Dry Eye Follow-Up Note
- Optometry Intermediate Eye Exam Note (Established Patient)
- Optometry Myopia Management Visit Note
- Optometry Pediatric Eye & Vision Examination Note
- Optometry Problem-Focused Eye Visit Note (Urgent/Same-Day)
- Optometry Refraction/Rx Check Note
- Oral and Maxillofacial Surgery Clinic Note (SOAP)
- Oral and Maxillofacial Surgery Consultation Note (Inpatient/ED)
- Oral Anticancer Therapy Monitoring Note
- Oral Anticancer Therapy Start Note
- Oral Food Challenge Procedure Note
- Oral Lesion Biopsy Procedure Note
- Organ Offer Review/Acceptance Note
- Orofacial Myofunctional Evaluation Report
- Orofacial Myofunctional Screening Note
- Orthobiologics Injection Procedure Note (PRP)
- Orthodontic Diagnostic Records Note
- Orthodontic Emergency Visit Note (Appliance Repair)
- Orthodontic Initial Consultation Note
- Orthodontic Progress Note (Periodic Treatment Visit)
- Orthodontic Retention Check Note
- Orthognathic Surgery Operative Note (Le Fort/BSSO/Genioplasty)
- Orthopedic Surgery Admission H&P
- Orthopedic Surgery Consultation Note (Inpatient)
- Orthopedic Surgery Discharge Summary
- Orthopedic Surgery Inpatient Progress Note
- Orthopedic Surgery Outpatient Progress Note
- Orthopedic Surgery Postoperative Follow-Up Note (Global Period)
- Orthopedic Surgery Preoperative Planning Note
- Orthosis/Splint Fabrication & Training Procedure Note
- Orthosis/Splint Follow-Up/Adjustment Note
- Orthotics & Prosthetics Device Delivery Note
- Orthotics & Prosthetics Device Fitting Procedure Note
- Orthotics & Prosthetics Follow-Up/Adjustment Note
- Orthotics & Prosthetics Initial Evaluation
- Orthotics & Prosthetics Measurement/Casting/3D Scan Procedure Note
- Orthotics & Prosthetics Repair/Replacement Procedure Note
- Orthotics & Prosthetics SOAP Note
- Orthotics, Bracing, or Taping Note
- Osteomyelitis/Diabetic Foot Infection Consult Note
- Osteopathic SOAP Note (Office Visit)
- Osteopathic Structural Exam Note (TART/Somatic Dysfunction)
- Osteoporosis Management Note (DXA Review & Antiresorptive Therapy)
- Osteoporosis Medication Administration Procedure Note (Injection/Infusion)
- Osteoporosis/Osteopenia Evaluation Note
- Ostomy Care Procedure Note
- OTA Supervision/Co-Signature Note
- Otitis Externa Visit Note
- Otolaryngology Consultation Note (Inpatient/ED)
- Otolaryngology Postoperative Follow-up Note
- Otolaryngology Preoperative History & Physical
- Otolaryngology SOAP Note (Outpatient)
- Outcome Measures/Progress Report (Dance/Movement Therapy)
- Outcome Tracking Note (Aromatherapy)
- Outpatient Clinic Transfer to Emergency Department/Hospital Note
- Outpatient Psychotherapy/Counseling Discharge/Termination Summary
- Overactive Bladder/Urinary Incontinence Management Note
- Overdose Education & Naloxone Distribution Note
- Overdose Risk Assessment & Harm Reduction Counseling Note
- Oxygen Therapy Initiation/Titration Note
- Pacemaker/ICD Implant Procedure Note (Pediatric)
- PACU Transfer of Care/Handoff Note (Anesthesia)
- Pain Management New Patient Consultation Note
- Pain Management Progress Note (SOAP)
- Pain Reassessment Note (Post-Intervention)
- Palatal Expander Placement/Activation Procedure Note
- Palliative Care Comfort Activity Note (Recreational Therapy)
- Palliative Care Consultation Note (Inpatient)
- Palliative Care Consultation Note (Outpatient)
- Palliative Care Follow-Up Note (Inpatient)
- Palliative Care Follow-Up Note (Outpatient)
- Palliative Care Progress Note
- Palliative Care Transition of Care Summary
- Palliative/Hospice Music Therapy Session Note
- Panchakarma Therapy Session Note
- PAP Therapy Follow-Up Note (Medicare/DME Compliance & Benefit)
- Pap/HPV Results Follow-Up Note
- Paracentesis Procedure Note
- Paracentesis/Thoracentesis Procedure Note
- Parent/Guardian Interview Summary (Evaluation)
- Patch Testing Note (Reading/Interpretation)
- Patch Testing Procedure Note (Application)
- Pathology Results Disclosure and Follow-Up Note
- Patient Communication Note (Portal Message, Phone, or Text)
- Patient Counseling Note (Essential Oil Use)
- Patient Education Note (Respiratory Medications/Devices)
- Patient Education Note (Teach-Back)
- Patient-Reported Outcome Review Note (PROMIS/PROs)
- Pediatric Appendicitis Nonoperative Management Note
- Pediatric Blunt Solid Organ Injury Management Note (Nonoperative)
- Pediatric Cardiology Clinic Note (SOAP)
- Pediatric Cardiology Consultation Note (Inpatient)
- Pediatric Cardiology Inpatient Progress Note
- Pediatric CKD Longitudinal Care Note
- Pediatric Consultation Note (Inpatient/ED)
- Pediatric Endocrinology Consultation Note (Inpatient)
- Pediatric Endocrinology Follow-Up Note (SOAP)
- Pediatric Endocrinology New Patient Consultation Note
- Pediatric Endocrinology Telemedicine Visit Note
- Pediatric Gastroenterology Inpatient Consult Note
- Pediatric Gastroenterology Inpatient Progress Note
- Pediatric Gastroenterology Outpatient Note (SOAP)
- Pediatric Genetics Evaluation Note (Congenital Anomalies, DD/ID)
- Pediatric Hypertension Evaluation Note
- Pediatric Inpatient Admission History & Physical
- Pediatric Inpatient Daily Progress Note
- Pediatric Inpatient Discharge Summary
- Pediatric Nephrology Consult Note (Inpatient)
- Pediatric Nephrology Inpatient Progress Note
- Pediatric Nephrology New Patient Consult Note (Outpatient)
- Pediatric Nephrology Outpatient Progress Note (SOAP)
- Pediatric Neurology Consultation Note (Inpatient)
- Pediatric Neurology Discharge Summary
- Pediatric Neurology Inpatient Progress Note
- Pediatric Neurology New Patient Consultation Note
- Pediatric Neurology Outpatient Progress Note
- Pediatric Neurology Telemedicine Visit Note
- Pediatric Obesity/Insulin Resistance Visit Note
- Pediatric Oncology Initial Consultation Note
- Pediatric Oncology SOAP Note
- Pediatric Psychology Progress Note (SOAP)
- Pediatric Pulmonology Discharge Summary (Primary Pulmonary Service)
- Pediatric Pulmonology Inpatient Consultation Note
- Pediatric Pulmonology Inpatient Progress Note (Primary Pulmonary Service)
- Pediatric Pulmonology New Patient Consultation Note
- Pediatric Pulmonology Outpatient Progress Note
- Pediatric Pulmonology Telehealth Visit Note
- Pediatric Suicide/Self-Harm Risk Assessment Note
- Pediatric Surgery Admission H&P
- Pediatric Surgery Clinic Consultation Note
- Pediatric Surgery Clinic Follow-Up Note
- Pediatric Surgery Consult Note (ED/Inpatient)
- Pediatric Surgery Daily Progress Note (Inpatient)
- Pediatric Surgery Discharge Summary
- Pediatric Surgery Operative Report (Full)
- Pediatric Surgery Postoperative Check Note
- Pediatric Surgery SOAP Note
- Pediatric/Neurodevelopmental Genetic Counseling Note
- Pediatrics Outpatient Progress Note (SOAP)
- Pediatrics Telemedicine Visit Note
- Peer Recovery Support Encounter/Care Coordination Note
- Pelvic Examination Note (Emergency Department)
- Pelvic Floor Biofeedback Therapy Initial Evaluation
- Pelvic Floor Biofeedback Therapy Session Note (Dyssynergic Defecation/Constipation)
- Pelvic Floor Biofeedback Therapy Session Note (Fecal Incontinence)
- Pelvic Floor Biofeedback Therapy Session Note (Urinary Incontinence)
- Pelvic Pain Evaluation Note
- Penicillin Allergy Delabeling Visit Note
- Percutaneous Endoscopic Gastrostomy (PEG)/Gastrostomy Tube Placement Procedure Note
- Percutaneous Tracheostomy Procedure Note
- Perforation Repair Procedure Note
- Peri-Procedural Reiki Procedure Note (Pre/Post-Procedure)
- Periodic Medical Surveillance Exam Note (Hazard Exposure)
- Periodic Oral Evaluation Note (Recall/Check-up)
- Periodic Reassessment/Continued Stay Review (ASAM Criteria)
- Periodontal Evaluation & Charting Note
- Peripheral IV Insertion/Removal Procedure Note
- Peripheral Joint/Bursa Aspiration and/or Injection Procedure Note (Landmark or Non-Dedicated Ultrasound)
- Peripheral Nerve Block Procedure Note
- Peripheral Nerve Block Procedure Note (Chronic Pain)
- Peripheral Neuropathy/Radiculopathy Evaluation Note
- Peritoneal Dialysis Clinic Follow-Up Note (Pediatric)
- Peritonsillar Abscess Drainage Procedure Note
- Pharmacokinetic Dosing Consult Note (Vancomycin/Aminoglycoside)
- Pharmacy SOAP Note
- Phenol Neurolysis Procedure Note
- Physical Activity Counseling Note
- Physical Therapy Daily Treatment Note (SOAP)
- Physical Therapy Discharge Summary (Episode of Care)
- Physical Therapy Initial Assessment
- Physical Therapy Initial Evaluation (Acute Care Inpatient)
- Physical Therapy Initial Evaluation & Plan of Care (Outpatient)
- Physical Therapy Inpatient Daily Note
- Physical Therapy Progress Report (Medicare 10-Visit/30-Day)
- Physical Therapy Re-evaluation
- Physical Therapy SOAP Note
- Physiotherapeutic Modalities Treatment Note
- PICC Line Placement Procedure Note (Neonate)
- Pituitary/Adrenal Axis Evaluation Note
- Plastic Surgery Clinic SOAP Note
- Plastic Surgery Consultation Note (Aesthetic Surgery)
- Plastic Surgery Consultation Note (Inpatient/ED)
- Plastic Surgery Office/Bedside Procedure Note
- PM&R Acute Care Consultation Note
- PM&R Inpatient Follow-Up Consultation Note
- PM&R Outpatient New Patient Evaluation (SOAP)
- PM&R Outpatient Progress Note (SOAP)
- Podiatry Consult Note (Inpatient/ED)
- Podiatry New Patient Evaluation Note
- Podiatry SOAP Note
- Point-of-Care Respiratory Virus Testing Encounter Note
- Point-of-Care Strep Test Encounter Note
- Poor Weight Gain/Hyperbilirubinemia Feeding Support Note
- Post-Acute Placement Coordination Note
- Post-AKI Clinic Follow-up Note
- Post-Anesthesia Evaluation Note
- Post-Anesthesia Recovery Note (Office/ASC)
- Post-Fall Assessment Note
- Post-Liver Transplant Follow-Up Note
- Post-Procedure Recovery/Discharge Note (Pain Procedures)
- Post-Transplant Clinic Follow-Up Note
- Post-Transplant Discharge Summary (Recipient)
- Post/Post-and-Core Removal Procedure Note
- Postoperative Check Note (PACU/POD 0)
- Postoperative Check Note (Student)
- Postoperative Check Note (Vascular Surgery)
- Postoperative Clinic Follow-Up Note (Global Period)
- Postoperative Follow-Up Note (Cataract/Anterior Segment)
- Postoperative Follow-Up Note (Foot/Ankle Surgery)
- Postoperative Follow-Up Note (Oral and Maxillofacial Surgery)
- Postoperative Follow-Up Note (Plastic Surgery)
- Postoperative Follow-Up Visit Note (Gynecologic Surgery)
- Postoperative Surveillance Visit Note (Carotid/EVAR/Bypass)
- Postoperative Telephone/Portal Encounter Note (Surgery)
- Postpartum Hemorrhage Event Note
- Postpartum Inpatient Daily Progress Note
- Pre-Anesthesia Evaluation Note
- Pre-Placement/Post-Offer Employment Physical Note
- Pre-Procedure History & Physical (Pediatric Endoscopy)
- Pre-Transplant Admission H&P (Recipient)
- Pre/Post-Frenectomy Myofunctional Therapy Note
- Precocious Puberty Evaluation Note
- Prenatal Genetics Consultation Note
- Prenatal Massage Session Note
- Preoperative Cardiac Evaluation Note (Noncardiac Surgery/Procedure)
- Preoperative Cardiac Risk Assessment Note (Noncardiac Surgery)
- Preoperative Evaluation Note (OMS Procedure)
- Preoperative Evaluation Note (Vascular Surgery)
- Preoperative H&P (Gynecologic Surgery)
- Preoperative History & Physical (Plastic Surgery)
- Preoperative History & Physical (Surgery)
- Preoperative Medical Evaluation Note (Medical Clearance)
- Preoperative Nutrition Clearance Note (Bariatric Surgery)
- Preoperative Pulmonary Risk Assessment
- PrEP Follow-up/Injection Visit Note
- PrEP Initiation Note
- Preparticipation Physical Evaluation (Sports Physical) Note
- Pressure Injury Assessment & Staging Note
- Preventive Care Visit Note (Wellness)
- Preventive Visit Note (Student)
- Primary Immunodeficiency Evaluation Note
- Principal Illness Navigation Monthly Note (PIN)
- Problem-Focused Dental Visit Note (Urgent/Emergency)
- Procedural Support Note (Pediatric Music Therapy)
- Progress Report (Myofunctional Therapy)
- Progress Report (Therapy Services)
- Progress Review Note (Clinical Hypnosis)
- Progress Review/Outcome Summary (Art Therapy)
- Progress Summary/Treatment Review (Drama Therapy)
- Prolonged Grief Disorder Assessment Note
- Prophylaxis/Preventive Services Note (Hygiene Visit)
- Prostate Cancer Counseling/Active Surveillance Note
- Prosthetic Check Socket Test-Fit Note
- Prosthetic Component Change/Upgrade Evaluation Note
- Provider Notification Note (Change in Condition/Critical Result)
- Psoriasis Systemic Therapy Note
- Psychiatric Collaborative Care Monthly Summary (CoCM)
- Psychiatry Medication Management Follow-Up Note
- Psychological Testing Administration/Behavioral Observations Note (Forensic)
- Psychological/Neuropsychological Assessment Feedback Session Note
- Psychosocial Assessment (Hospice Social Work)
- Psychosocial Assessment Note (Palliative Care Social Work)
- Psychosocial Distress Screening & Triage Note
- Psychotherapy Process Note (Play Therapy)
- Psychotherapy Progress Note (BIRP)
- Psychotherapy Progress Note (DAP, Child/Adolescent)
- Psychotherapy Session Progress Note (SOAP)
- Pulmonary Consultation Note (Inpatient)
- Pulmonary Rehabilitation Referral Note
- Pulmonary Rehabilitation Session Note
- Pulmonary/Critical Care ICU Daily Progress Note
- Pulmonology New Patient Consultation Note (Outpatient)
- Pulmonology SOAP Note
- Pumping/Hand Expression Teaching Note
- Punctal Plug Insertion Procedure Note
- Pyloromyotomy Operative Note
- Radiation Oncology Consultation Note
- Radiation Therapy CT Simulation Procedure Note
- Radiation Therapy Follow-Up Visit Note
- Radiation Therapy Inpatient Consultation Note (Urgent/Palliative)
- Radiation Therapy On-Treatment Visit Note
- Radiation Therapy Peer Review Note (Contour/Plan Review)
- Radiation Therapy Re-Simulation/Re-Planning Note
- Radiation Therapy Toxicity Check Note (Unscheduled Visit)
- Radiation Therapy Treatment Completion Summary
- Radiofrequency Microneedling Procedure Note
- Radiograph Order & Preliminary Interpretation Note
- Radiology Overread Discrepancy Addendum Note
- Radiology Protocol Note (CT/MRI, Contrast)
- Radionuclide Therapy Administration Procedure Note (Theranostics)
- Radionuclide Therapy Consult Note (Theranostics)
- Raktamokshana Procedure Note (Bloodletting/Leech Therapy)
- Rapid Drug Desensitization Procedure Note
- Rapid Genomic Sequencing Note (Inpatient)
- Re-Evaluation Note (Animal-Assisted Therapy)
- Record Review Summary (Forensic)
- Recreational Therapy Consultation Note
- Recreational Therapy Discharge Summary
- Recreational Therapy Group Session Note
- Recreational Therapy Incident/Safety Event Note
- Recreational Therapy Initial Evaluation
- Recreational Therapy Progress Note (DARP)
- Recreational Therapy Reassessment/Progress Report
- Recreational Therapy Session Note (SOAP, In-Person/Telehealth)
- Recurrent UTI/VUR Co-Management Note (Pediatric)
- Reduction Mammaplasty Operative Note
- Referral Letter
- Referral/Transfer Summary (Specialty/ER)
- Reflexology Reassessment Note
- Reflexology Session Note (Oncology Supportive Care)
- Reflexology Session Note (Pregnancy/Postpartum)
- Reflexology Session Note (Seated/Chair)
- Reflexology Session Note (SOAP)
- Regenerative Endodontics/Apexification Procedure Note
- Regional Anesthesia Catheter Follow-Up Note
- Rehabilitation Psychology Discharge Summary
- Rehabilitation Psychology Intake Assessment (Biopsychosocial)
- Rehabilitation Psychology SOAP Note
- Reiki Session Note
- Relapse/Return-to-Use Event Note
- Renal/Hepatic Dose Adjustment Note
- Repertorization & Remedy Selection Note
- Respiratory Care Protocol Assessment Note
- Respiratory Therapy Initial Assessment Note (Inpatient)
- Respiratory Therapy Progress Note (Inpatient)
- Restraint/Seclusion Episode Note
- Results Review Note (Herbal Medicine)
- Resuscitation (Code Blue/CPR) Event Note
- Retainer Delivery Note
- Retinal Laser Photocoagulation Procedure Note (PRP/Focal/Grid)
- Return to OR for Post-Transplant Complication Operative Note
- Return-to-Flight Evaluation (Post-Illness/Injury)
- Return-to-Work Clearance Exam Note
- Rheumatoid Arthritis Treat-to-Target Visit Note (Disease Activity & Function)
- Rheumatology Follow-Up Note (Treat-to-Target Chronic Disease)
- Rheumatology New Patient Consultation Note
- Rheumatology SOAP Note
- Root Canal Retreatment Procedure Note (Nonsurgical)
- Routine Foot Care Visit (Medicare)
- Routine Prenatal Follow-Up Visit Note
- Sacroiliac Joint Injection Procedure Note
- Safety Risk Assessment Note (Suicide/Homicide)
- Safety/Risk Assessment & Safety Plan (Child/Adolescent Therapy)
- Same-Day Acute Visit Note (Adult Internal Medicine)
- SBAR Communication Note
- SBIRT Note (Screening, Brief Intervention, and Referral to Treatment)
- SBIRT Screening, Brief Intervention & Referral Note
- Scaling and Root Planing Procedure Note
- School Consultation Note (Child/Adolescent Psychiatry)
- School Consultation Note (IEP/504 or Behavioral Support)
- School Psychology Progress Note (Student Support)
- School-Based DMT Session Note
- School-Based Horticultural Therapy Note (IEP/504-Aligned)
- School-Based Medicaid Service Note (Psychological Counseling)
- School-Based Music Therapy Session Note (IEP-Linked)
- School-Based OT Service Note (IEP/504)
- School-Based Service Note (Art Therapy)
- School-Based Session Note (Play Therapy)
- Sclerotherapy Procedure Note
- Sedation/Anesthesia Necessity Note (Spinal Pain Procedures)
- Selective Laser Trabeculoplasty Procedure Note
- Self-Hypnosis Training Note
- Sensory Integration Intervention Note (Pediatric)
- Sepsis Evaluation/Bundle Note
- Sepsis/Septic Shock Management Note
- Sexual Abuse Medical Forensic Exam Note (Pediatric/Prepubescent)
- Sexual Assault Medical-Forensic Exam Note (Adult/Adolescent)
- Sexual Offense Risk Assessment Report
- Shared Decision-Making Note (Carotid Revascularization)
- Shared Medical Appointment/Group Medical Visit Note
- Shock Wave Lithotripsy Operative Note
- Shodhana Procedure Note (Virechana)
- Short Stature/Growth Evaluation Note
- Shoulder Arthroscopy/Rotator Cuff Repair Operative Report
- Shoulder Dystocia Event Note
- Sickle Cell Disease Comprehensive Visit Note
- Sideline Injury Evaluation Note (Acute On-Field)
- Sideline/Training Room Encounter Note
- Simultaneous Liver-Kidney Transplant Operative Note
- Skin Biopsy Procedure Note
- Skin Biopsy Procedure Note (Incisional)
- Skin Biopsy Procedure Note (Punch)
- Skin Biopsy Procedure Note (Tangential/Shave)
- Skin Cancer Excision & Reconstruction Operative Note
- Skin Cancer Surveillance Follow-Up Note
- Skin Lesion Procedure Note (Biopsy, Excision, or Cryotherapy)
- Skin Substitute/CTP Application Procedure Note
- Skin/Soft Tissue Abscess Incision and Drainage Procedure Note
- Sleep Health Coaching Note
- Sleep Medicine Evaluation Note (Central Sleep Apnea/Hypoventilation)
- Sleep Medicine Evaluation Note (Hypersomnia/Narcolepsy)
- Sleep Medicine Evaluation Note (Restless Legs Syndrome/PLMD)
- Sleep Medicine Follow-Up Note (Insomnia Management)
- Sleep Medicine Follow-Up Note (PAP Therapy Management)
- Sleep Medicine Initial Consultation Note (Comprehensive Sleep Evaluation)
- Sleep Medicine SOAP Note
- Sleep Medicine Visit Note (Sleep Study Results Review)
- Sleep-Disordered Breathing/OSA Myofunctional Therapy Note
- SMART Goal
- SNF Skilled Nursing Progress Note (Medicare Skilled Need)
- SOAP Note
- SOAP Note (Art Therapy)
- SOAP Note (Therapy)
- Social Determinants of Health (SDOH) Assessment/Risk Assessment Note
- Social Skills Training Group Note (Recreational Therapy)
- Soft Tissue Excision/Biopsy Operative Note (Skin/Subcutaneous Mass)
- Soft Tissue Surgery Procedure Note
- Soft Tissue/Myofascial Release Procedure Note
- Spay/Neuter Surgery Note
- Speech-Language Evaluation Report (Pediatric Outpatient)
- Speech-Language Pathology Consult Note (Acute Care)
- Speech-Language Pathology Daily Treatment Note (SOAP)
- Speech-Language Pathology Discharge Summary (Therapy Episode)
- Speech-Language Pathology Initial Evaluation Report (Outpatient Medical)
- Speech-Language Pathology Progress Report (10-Visit/30-Day)
- Spinal Cord Stimulator Implant Procedure Note
- Spinal Cord Stimulator Trial Procedure Note
- Spinal Fusion Operative Report
- Spinal Orthosis Evaluation Note (LSO/TLSO)
- Spinal/Epidural Anesthesia Procedure Note
- Spine Injection Procedure Note (Epidural/Facet/Medial Branch Block)
- Spine Radiofrequency Ablation Procedure Note
- Spiritual Care Assessment Note (Hospice Chaplain)
- Spiritual Care Assessment Note (Palliative Care Chaplain)
- Splint, Cast, or Immobilization Procedure Note
- Splinting/Spinal Motion Restriction Procedure Note (EMS)
- Spontaneous Breathing Trial Procedure Note
- Sports Massage Session Note
- Sports Medicine Follow-Up Visit Note
- Sports Medicine New Patient Evaluation (Comprehensive MSK)
- Sports Medicine SOAP Note
- Sports Psychology Session Note (DAP)
- Sports/School Physical Examination & Clearance Note (PPE)
- SRS/SBRT Treatment Delivery Note
- Staphylococcus aureus Bacteremia/Endocarditis Management Note
- Stress Management & Mindfulness Coaching Note
- Stress Management/Relaxation Session Note (Recreational Therapy)
- Stroke Alert Note
- Stroke/TIA Clinic Note
- Student Clinical Encounter Write-Up (Educational/De-identified)
- Student Discharge Summary Draft
- Student History & Physical (Admission)
- Student Informed Consent Note (Supervised)
- Student Inpatient Progress Note
- Student Procedure Note (Observed/Assisted)
- Student SOAP Note
- Student Telephone/Portal Encounter Note
- Substance Use Counseling Session Progress Note
- Substance Use Disorder Discharge Summary & Continuing Care Plan
- Substance Use Disorder Group Counseling Session Note
- SUD Case Management/Care Coordination Note
- SUD Confidentiality & Consent Documentation Note (42 CFR Part 2)
- SUD Level-of-Care Assessment & Placement Recommendation Note
- SUD Treatment Plan Review/Update Note
- Suicide Risk Assessment (School Setting)
- Suicide Risk Assessment & Patient-Facing Safety Plan Note
- Suicide/Self-Harm Risk Assessment & Safety Plan Note
- Supplement/Herbal Recommendation Note
- Surfactant Administration Procedure Note (Neonate)
- Surgery Clinic Consultation Note (New Patient)
- Surgery Progress Note (SOAP)
- Surgical Admission H&P (Inpatient)
- Surgical Consent Discussion Note (Pediatrics)
- Surgical Consultation Note (Inpatient/ED)
- Survivorship Clinic Note (COG LTFU-Based)
- Suspected Ankyloglossia Screening/Referral Note
- Suture/Staple Removal Procedure Note
- Swallowing Treatment Note (Dysphagia)
- Symptom Crisis Visit Note (Hospice PRN/After-Hours)
- Symptom Management Note (Non-Pain Symptoms)
- Symptom Management Note (Pain and Opioids)
- Syncope Evaluation Note (Pediatric Cardiology)
- Systemic Lupus Erythematosus Follow-Up Note
- Taping/Strapping Procedure Note
- Team Workshop/Seminar Note (Mental Skills Training)
- Technician-Administered Testing Supervision Note
- Teleaudiology Visit Note
- Teledermatology Visit Note
- Telehealth OT Visit Note
- Telehealth Psychotherapy Addendum
- Telehealth Rheumatology Visit Note
- Telehealth Visit Note (Family Medicine)
- Telehealth Visit Note (Herbal Medicine)
- Telehealth/Telephone Encounter Note
- Telemedicine Visit Note
- Telephone Triage/Advice Note (Pediatrics)
- Telephone/MyChart Encounter Note (Pediatric GI)
- Telephone/Portal Encounter Note (Care Coordination)
- Telepsychiatry Visit Note (Audio/Video)
- Telepsychiatry Visit Note (Child & Adolescent Psychiatry)
- Temporary Non-Tunneled Hemodialysis Catheter Placement Procedure Note
- Tendon Sheath/Ligament Injection Procedure Note
- Termination/Discharge Summary (Grief Counseling)
- TEVAR Procedure Note
- Therapeutic Botulinum Toxin Injection (Chemodenervation) Procedure Note
- Therapeutic Diet Order Recommendation Note
- Therapeutic Phlebotomy Procedure Note
- Therapeutic Plasma Exchange Procedure Note
- Therapeutic Plasma Exchange/Apheresis Management Note (Pediatrics)
- Therapeutic Shoes & Inserts Note (Diabetes)
- Therapeutic Yoga Discharge/Program Completion Summary
- Therapy Discharge Summary (CBT Course of Care)
- Therapy Evaluation Note (Home Health)
- Therapy Treatment Note (Home Health)
- Third Molar Extraction Operative Note
- Thoracentesis Procedure Note
- Threat Assessment (School Setting)
- Thrombocytopenia Evaluation Note
- Thyroid Disorder Follow-Up Note (Hypothyroidism/Hashimoto)
- Thyroid Fine-Needle Aspiration Procedure Note
- Thyroid Function Disorder Follow-Up Note
- Thyroid Nodule Evaluation Note
- Thyroid Nodule/Goiter Evaluation Note
- Thyroidectomy Operative Note
- Tic Disorder/Tourette Syndrome Clinic Note
- Tinnitus Evaluation & Management Note
- TMJ Arthrocentesis/Injection Procedure Note
- Tobacco Cessation Coaching Note (5 A's)
- Tonsillectomy/Adenoidectomy Operative Note
- Tooth Extraction/Alveoloplasty Procedure Note
- Total Hip Arthroplasty Operative Report
- Total Knee Arthroplasty Operative Report
- Total-Body Skin Exam Note
- Tracheostomy & Home Mechanical Ventilation Follow-Up Note
- Tracheostomy Care Note (Acute Care)
- Traditional Chinese Medicine Consultation Note (Integrative Care)
- Traditional Chinese Medicine Follow-Up SOAP Note (Acupuncture/Herbal Medicine)
- Traditional Chinese Medicine Initial Evaluation Note (Four Examinations)
- Traditional Chinese Medicine Re-evaluation/Progress Report (Episode of Care)
- Transfer of Care Summary (Orthodontics)
- Transfer of Postoperative Care Note (Global Surgery)
- Transfusion Order & Consent Note
- Transfusion Reaction Evaluation Note
- Transition of Care Outreach Note (Post-Discharge)
- Transition of Care Summary (Pediatric Endocrinology to Adult Care)
- Transition of Care Summary (Pediatric-to-Adult Nephrology)
- Transitional Care Management (TCM) Post-Discharge Follow-Up Note
- Transitions of Care Medication Review Note (Post-Discharge)
- Transplant Candidate Surgical Evaluation Note
- Transplant Informed Consent Discussion Note (Recipient)
- Transplant Psychosocial Evaluation Report (SIPAT-Informed)
- Transplant Selection Committee Decision Note
- Transplant Selection Committee Presentation Note
- Transplant Surgery Inpatient Consult Note
- Transplant Surgery SOAP Note
- Transrectal Prostate Biopsy Procedure Note
- Trauma Activation (Resuscitation) Note
- Trauma Clinic Follow-Up Note
- Trauma Discharge Summary
- Trauma ICU Progress Note (Systems-Based)
- Trauma Interfacility Transfer Note
- Trauma Post-Op Check Note
- Trauma Surgery Admission H&P
- Trauma Surgery Consult Note (ED/Inpatient)
- Trauma Surgery Inpatient Progress Note (SOAP)
- Trauma Tertiary Survey Note
- Trauma-Focused CBT Session Note (PTSD)
- Traumatic Dental Injury Note (Endodontic Assessment/Plan)
- Treatment Plan Modification Note (Midcourse Review)
- Treatment Plan, Cost Estimate & Informed Consent Discussion Note
- Trial of Void/PVR Assessment Procedure Note
- Trichiasis Epilation Procedure Note
- Trigger Point Injection Procedure Note
- Trigger Point/Tendon Sheath Injection Procedure Note
- Type 1 Diabetes Admission Note (New Diagnosis)
- Type 1 Diabetes Follow-Up Note (CGM/Pump)
- Ultrasound-Guided Joint Aspiration/Injection Procedure Note
- Umbilical Catheter Placement Procedure Note (UAC/UVC)
- Urgent Care Encounter Note
- Urgent Care Result Review & Patient Notification Note
- Urgent Care Telehealth Encounter Note
- Urinalysis/Urine Culture Collection Note (Pediatrics)
- Urinary (Foley) Catheter Placement, Change, or Removal Procedure Note
- Urinary Catheter Care/Change Procedure Note
- Urine Drug Screen/Toxicology Interpretation Note
- Urine Drug Screen/Toxicology Results Interpretation Note
- Urology Consultation Note (Inpatient/ED)
- Urology Follow-Up/Surveillance Visit Note
- Urology Office Visit Note (SOAP)
- Urology Operative Note (TURBT/Fulguration)
- Urology Operative Note (TURP/HoLEP)
- Urology Operative Note (Ureteroscopy with Laser Lithotripsy +/- Stent)
- Urology Postoperative Follow-Up Note
- Urology Preoperative Planning Note
- Utilization Review/Medical Necessity Review Note
- Vaccination Counseling Note (Homeopathy Context)
- Vaginal Delivery Procedure Note
- Vaginitis/STI Evaluation Note
- Vamana Procedure Note (Shodhana)
- Variant Reclassification Addendum Note
- Variant Reinterpretation/Reclassification Note
- Vascular Access Procedure Note (IV/IO)
- Vascular Access Procedure Note (PICC/Central Line)
- Vascular Surgery Consultation Note (Inpatient)
- Vascular Surgery SOAP Note
- Vasectomy Procedure Note
- Venipuncture/Specimen Collection Procedure Note (Home Health)
- Venous Leg Ulcer Clinic Note
- Ventilator Check Note (Mechanical Ventilation)
- Ventilator Management Note (Critical Care)
- Vestibular Evaluation & Treatment Note (BPPV/Dizziness)
- Veterinary SOAP Note
- Violence Risk Assessment Report (General)
- Vital Pulp Therapy Procedure Note (Pulpotomy/Pulp Cap/Apexogenesis)
- Vocational Horticultural Therapy Progress Note (Job Skills/Productivity)
- Voice Evaluation Report
- Waitlist Status Change Documentation Note
- Weight Management & Nutrition Coaching Note
- Well-Child Visit Note (Bright Futures)
- Well-Child Visit Note (Child/Adolescent)
- Well-Child Visit Note (Infant/Toddler)
- Well-Woman/Gynecologic Preventive Visit Note
- Wellness & Prevention Visit Note (Naturopathic)
- Wellness Coordinator Encounter Note (SOAP)
- Wellness Program Discharge/Graduation Summary
- Wheelchair Seating & Mobility Evaluation Note
- Whirlpool Hydrotherapy Treatment Note (Wound/Burn)
- Withdrawal Management Admission Note (Alcohol, Opioid, or Sedative)
- Withdrawal Management Daily Progress Note
- Women's Health/Hormonal Visit Note (Naturopathic)
- Workers’ Compensation Follow-up/Return-to-Work Progress Note
- Workers’ Compensation/Personal Injury Initial Injury Evaluation Note
- Wound Biopsy Procedure Note
- Wound Care & Dressing Change Procedure Note
- Wound Care Follow-Up/Progress Note
- Wound Care Initial Evaluation Note
- Wound Care Note (Hospice)
- Wound Care Procedure Note (Assessment, Dressing Change, or NPWT)
- Wound Culture/Specimen Collection Procedure Note
- Wound Debridement Procedure Note
- Wound/Drain Check Note (Surgery)
- Wound/Laceration Repair Procedure Note
- Wound/Pressure Injury Assessment & Dressing Change Note
- YAG Posterior Capsulotomy Procedure Note
- Yoga Therapy Initial Evaluation & Plan of Care
- Yoga Therapy Re-evaluation/Progress Report
- Yoga Therapy Safety Screening & Contraindications Note
- Yoga Therapy Session Note (SOAP, In-Person/Telehealth)
Interpretation / Results Report182
- 504 Accommodation Evaluation Summary
- ABPM Interpretation Report (Pediatrics)
- Actigraphy Interpretation Report
- Ambulatory ECG Monitor Interpretation Report (Holter/Event/Patch)
- Anorectal Manometry Interpretation Report
- Assistive Technology Assessment Report
- Auditory Processing Disorder Evaluation Report
- Automated Perimetry Visual Field Interpretation Report
- Autopsy Report (Hospital/Non-Forensic)
- Behavior Progress Monitoring Summary
- Body Composition Analysis Report (BIA/DXA)
- Bone Age Interpretation Report
- Bone Scintigraphy Interpretation Report
- Cancer Synoptic Report (Breast Resection)
- Cancer Synoptic Report (Colon/Rectum Resection)
- Cancer Synoptic Report (Lung Resection)
- Cancer Synoptic Report (Prostatectomy)
- Cancer Synoptic Report (Uterine Corpus Resection)
- Capsule Endoscopy Interpretation Report
- Cardiac Catheterization/Coronary Angiography Procedure Report
- Cardiac Stress Test Procedure Note/Interpretation
- Child Custody/Parenting Plan Evaluation Report
- CIED Interrogation/Programming Report
- Civil Capacity Evaluation Report (Guardianship, Testamentary, or Medical)
- Classroom Observation Report (Academic/Behavioral)
- Cochlear Implant Candidacy Evaluation Report
- Colonoscopy Procedure Report
- Combined Upper Endoscopy (EGD)/Colonoscopy Procedure Report
- Competence to Stand Trial Evaluation Report
- Comprehensive Hearing Evaluation Report (Audiology)
- Comprehensive Neuropsychological Evaluation Consult Report
- Continuous Glucose Monitoring Interpretation Report
- Continuous Video-EEG Monitoring Report (ICU/EMU)
- Corneal Topography/Tomography Interpretation Report
- Coronary CT Angiography Report (CAD-RADS)
- Corrected/Amended Pathology Report
- Criminal Responsibility (Insanity) Evaluation Report
- CT Report (Diagnostic)
- Cytopathology Report (Cervicovaginal Pap Test)
- Cytopathology Report (Fine-Needle Aspiration)
- Cytopathology Report (Non-Gynecologic)
- Death Scene Investigation Report
- Deaths in Custody Investigation Report
- Dental Radiograph Interpretation Report
- Developmental Screening Interpretation Note
- Developmental Test Administration Report
- Diagnostic Polysomnography (PSG) Interpretation Report
- Diagnostic Radiology Interpretation Report (General)
- Differentiated Thyroid Cancer Whole-Body Scan Report
- DXA Bone Densitometry Report
- EBUS-TBNA Procedure Note
- ECG Acquisition and Interpretation Note
- ECG Interpretation Report (Pediatric)
- Echocardiogram Report (Pediatric Transthoracic)
- EGD Procedure Note (Variceal Screening/Banding)
- Electrodiagnostic Study Interpretation Report (EMG/NCS)
- Eligibility Determination Documentation (IDEA)
- EMG/Nerve Conduction Study Report (Pediatric)
- Endoscopic Mucosal Resection (EMR) Procedure Note
- ERCP Procedure Report
- Esophageal Manometry Interpretation Report
- Esophageal pH-Impedance Reflux Monitoring Interpretation Report
- Exercise Stress Test Report (Pediatric)
- Exercise Testing Interpretation Note (Exercise Challenge/CPET)
- FAST/eFAST Ultrasound Procedure Note
- FEES Report (Swallowing Endoscopy)
- FeNO Interpretation Note
- Fetal Echocardiogram Report
- Fitness-for-Duty Evaluation Report
- Flexible Fiberoptic Laryngoscopy Procedure Note
- Flexible Sigmoidoscopy Procedure Report
- Flow Cytometry Interpretation Report
- Fluorescein Angiography Interpretation Report
- Foot/Ankle Radiograph Interpretation Report
- Forensic Autopsy Report
- Forensic Autopsy Report Addendum (Ancillary Results)
- Forensic Psychological Evaluation Report (General Psycholegal)
- Forensic Report Addendum/Supplemental Opinion
- Forensic Toxicology Interpretation Addendum
- Frozen Section/Intraoperative Consultation Report
- Functional Behavioral Assessment (FBA) Report
- Functional Capacity/Disability Evaluation Report
- Functional Medicine Lab Review Report
- Fundus Photography Interpretation Report
- Gastric Emptying Study Report
- GI Bleeding Scan Report
- GI Endoscopy Procedure Report
- Hearing Screening Report
- Hematopathology Report (Bone Marrow Aspirate/Biopsy)
- Hepatobiliary (HIDA) Scan Report
- Home Oxygen Qualification Evaluation Report
- Home Safety Evaluation Report (OT)
- Home Sleep Apnea Test Interpretation Report (HSAT)
- Hydrogen Breath Test Interpretation Report
- IEP Evaluation Report (Speech-Language)
- Immunohistochemistry/Special Stain Addendum
- Infection/Inflammation (Tagged WBC) Scan Report
- Intradermal/Sequential Allergy Testing Report
- Liver Elastography Report (Transient Elastography)
- Liver Imaging Report (LI-RADS)
- Lower-Limb Prosthetic Functional Level Assessment (K0-K4)
- Lung Cancer Screening CT Report (Lung-RADS)
- Maintenance of Wakefulness Test (MWT) Interpretation Report
- Mammography Report (Diagnostic, BI-RADS)
- Mammography Report (Screening, BI-RADS)
- Medico-Legal Records Review Summary Report
- Medicolegal Death Investigation Report
- Modified Barium Swallow Study Report (VFSS/MBSS)
- Molecular Pathology Report (Somatic Tumor NGS)
- MRI Report
- MUGA (Radionuclide Ventriculography) Report
- Multiple Sleep Latency Test Interpretation Report (MSLT)
- Musculoskeletal Ultrasound Interpretation Report
- Myocardial Perfusion Imaging Interpretation Report
- Neuropsychological Evaluation Report (ADHD/Learning Disorders)
- Neuropsychological Evaluation Report (Concussion/mTBI)
- Neuropsychological Evaluation Report (Dementia/MCI-Focused)
- Neuropsychological Evaluation Report (Re-evaluation/Serial Comparison)
- Newborn Hearing Screening Report
- Nuclear Medicine Interpretation Report (General)
- Occupational Hearing Conservation Evaluation Report
- OCT Interpretation Report (Macula/Retina)
- OCT Interpretation Report (Optic Nerve/RNFL)
- Office Spirometry Procedure/Interpretation Report
- Oncology PET/CT Interpretation Report
- Ototoxicity Monitoring Report
- Overnight Oximetry Interpretation Report
- Parathyroid Sestamibi Scan Report
- Pathology Consultation Report (Outside Slide Review)
- Pediatric Audiology Evaluation Report (Behavioral Testing)
- Pediatric Diagnostic ABR/ASSR Report
- Percutaneous Coronary Intervention (PCI) Procedure Report
- Personal Injury/Psychological Damages Evaluation Report
- Physical Performance Test/Functional Testing Report
- Point-of-Care Testing Addendum (Respiratory, Urine, or Pregnancy)
- Point-of-Care Ultrasound (POCUS) Report
- Polysomnography Interpretation Report (PAP Titration PSG)
- Polysomnography Interpretation Report (Split-Night PSG)
- Postmortem External Examination Report (No Autopsy)
- Pre-Surgical Neuropsychological Evaluation Report
- Prostate MRI Report (PI-RADS)
- Psychoeducational Evaluation Report (Initial Special Education Eligibility)
- Psychoeducational Reevaluation Report (Triennial/Reevaluation)
- Psychological Assessment Report (Pediatric)
- Psychological Disability Evaluation Report
- Psychological Testing Report (Psychodiagnostic Evaluation)
- Pulmonary Function Test Interpretation Report
- Radiology Addendum/Corrected Report
- Renal Scintigraphy (Diuretic Renogram) Report
- Resting Metabolic Rate/Indirect Calorimetry Report
- Routine EEG Interpretation Report
- School-Based OT Evaluation Report (IEP/504)
- Sentinel Lymph Node Mapping Procedure Note
- Six-Minute Walk Test Report
- Skin Prick Testing Report
- Social-Emotional/Behavioral Assessment Report
- Spirometry Interpretation Note (Occupational Surveillance)
- Spirometry/PFT Report (Pre/Post Bronchodilator)
- Stress Echocardiography Report
- Surgical Pathology Report (Biopsy/Excision)
- Surgical Pathology Report (Complex Resection)
- Test Results Interpretation & Integration Report (Forensic)
- Thyroid Ultrasound Report (Risk Stratification)
- Thyroid Uptake and Scan Report
- Transesophageal Echocardiogram Report
- Transfusion Reaction Workup Report
- Transthoracic Echocardiogram Report
- Ultrasound Report (Diagnostic)
- Unidentified Remains Identification Report
- Upper Endoscopic Ultrasound (EUS) Procedure Report
- Upper Endoscopy (EGD) Procedure Report
- Upper GI Bleeding Endoscopic Hemostasis Procedure Note
- Urodynamics Study Report
- Variceal Band Ligation Procedure Note
- Venom Allergy Testing Report
- Ventilation/Perfusion (V/Q) Lung Scan Report
- Vestibular Evaluation Report (ENG/VNG)
- Vestibular Test Battery Addendum (Calorics/Rotational/VEMP)
- Vision/Color Screening Note (Occupational Medicine)
- Wheelchair Seating & Mobility Evaluation Report
- Worksite/Ergonomic Assessment Report
- X-ray Report
Plan85
- Academic Intervention Plan (MTSS Tier 2/3)
- Acupuncture Plan of Care
- Aromatherapy Treatment Plan & Home Program
- Behavior Intervention Plan (BIP)
- Behavior Management Plan (Inpatient Rehabilitation)
- Behavioral Activation Plan (Depression)
- Behavioral Care Plan (Dementia-Related Behaviors/BPSD)
- Behavioral Health Treatment Plan (Medical Setting)
- Behavioral Health Treatment Plan (Person-Centered)
- Biofeedback Therapy Plan of Care
- Care Coordination Plan (Neurodevelopmental Disorders)
- Care Plan (Case Management)
- CBT Treatment Plan (Initial)
- Chemotherapy Treatment Plan Note (Pediatric Oncology)
- Chronic Care Management (CCM) Care Plan and Monthly Service Log
- Complex Care Plan (Children with Special Health Care Needs)
- Creative Arts Therapy Treatment Plan Review/Update
- Diabetes Medical Management Plan (School Orders/DMMP)
- Equine Therapy Plan of Care
- Exposure Hierarchy Plan (Exposure/ERP)
- Grief Counseling Treatment Plan (Psychotherapy)
- Hepatocellular Carcinoma Surveillance/Recall Note
- Home Health Plan of Care/Physician Orders (485-Style)
- Home Safety Assessment & Fall Prevention Plan
- Horticultural Therapy Plan of Care or Treatment Plan
- Horticultural Therapy Session Plan (Activity Programming)
- Hospice Bereavement Risk Assessment and Plan of Care (Family)
- Hospice Plan of Care (Interdisciplinary)
- Interdisciplinary Care Plan Update (Recreational Therapy)
- Interdisciplinary Team Conference Note (Long-Term Care)
- Interdisciplinary Team Plan of Care Note (Palliative Care)
- IRF Individualized Overall Plan of Care
- Massage Therapy Plan of Care
- Mental Performance Plan (Goal Setting & Skills Training)
- MTSS/RTI Problem-Solving Team Note
- Multidisciplinary Pain Care Plan
- Music Therapy Treatment Plan (Plan of Care)
- Nursing Care Plan (NANDA/NIC/NOC)
- Occupational Therapy Initial Evaluation & Plan of Care
- OPAT Care Plan (Initial)
- Orthodontic Comprehensive Evaluation & Treatment Plan
- Outpatient Psychotherapy Treatment Plan
- Panchakarma Treatment Plan (Course Protocol)
- Peri-Endoscopy Anticoagulation/Antiplatelet Plan
- Perioperative Anticoagulation/Hemostasis Plan
- Personal Health Plan (Whole Health)
- Physical Therapy/Occupational Therapy Referral & Rehab Plan
- Plan of Care (Athletic Therapy Rehabilitation)
- Plan of Care (Myofunctional Therapy)
- Plan of Care Certification Request (Aquatic Therapy)
- Prenatal Care Plan (Risk-Stratified/Tailored)
- Psychotherapy Treatment Plan (Pediatric Psychology)
- Psychotherapy Treatment Plan Review/Update
- Pulmonary Rehabilitation Initial Evaluation & Individualized Treatment Plan
- Radiation Therapy Plan Approval Note (DVH/Isodose Summary)
- Radiation Therapy Treatment Planning & Dose Constraints Plan
- Radiation Therapy Treatment Prescription
- Recreational Therapy Plan of Care
- Reflexology Treatment Plan (Course of Care)
- Reiki Treatment Plan (Episode of Care)
- School-Based Music Therapy IEP Contribution Report
- Speech-Language Pathology Plan of Care (Outpatient Therapy)
- SUD Initial Treatment Plan (Person-Centered)
- Supplement/Herbal Therapy Plan (Naturopathic)
- Supplementation/Feeding Plan Note
- Survivorship Care Plan (Post-Treatment)
- Systemic Therapy Treatment Plan (Chemotherapy/Immunotherapy)
- Therapy Prescription & Plan of Care (PT/OT/SLP)
- Treatment Plan (Art Therapy)
- Treatment Plan (ASAM-Aligned)
- Treatment Plan (Clinical Hypnosis)
- Treatment Plan (Dance/Movement Therapy)
- Treatment Plan (Marriage and Family Therapy)
- Treatment Plan (Play Therapy)
- Treatment Plan (Psychotherapy—Older Adult)
- Treatment Plan (Sports Psychology)
- Treatment Plan or Plan of Care (Animal-Assisted Therapy)
- Treatment Plan or Plan of Care (Drama Therapy)
- Treatment Plan Review/Update (Play Therapy, 90-Day)
- Treatment Plan Review/Update (Psychotherapy—Older Adult)
- Treatment Plan Review/Update (Psychotherapy)
- Treatment Plan Review/Update (SUD)
- Treatment Plan Summary (Herbal Medicine)
- Vascular Access Evaluation and ESKD Life-Plan Note
- Wound Care Discharge/Transition Plan
Patient Instructions70
- Adrenal Insufficiency Emergency Plan (Stress-Dosing Letter)
- Anaphylaxis Emergency Action Plan
- Aquatic Therapy Home Program Instructions
- Asthma Action Plan
- Asthma Action Plan (School/Home)
- Ayurvedic Medication/Herbal Formulation Prescription
- Behavioral Health Suicide/Self-Harm Safety Plan
- CMR Patient Summary (Cover Letter, Personal Medication List, and Medication Action Plan)
- Crisis/Safety Plan (Suicide/Self-Harm/Overdose Risk)
- Diet & Lifestyle Instructions (Pathya/Apathya & Vihara)
- Discharge Nutrition Plan
- Emergency Department Discharge Instructions (Patient-Facing)
- Endoscopy Post-Procedure Note and Discharge Instructions
- Home Care & Self-Management Instructions (Massage Therapy)
- Home Exercise & Self-Care Program Instructions
- Home Exercise Program (Myofunctional Therapy)
- Home Practice Plan (Hypnosis/Self-Hypnosis)
- Home Practice Plan (Yoga Therapy)
- Homeopathic Remedy Dosing Instructions (Patient Handout)
- Hospital Discharge Instructions (Veterinary)
- Hypnosis Script/Recording Instructions
- Lactation Care Plan (After Visit Summary)
- Pathology Results Communication (Endoscopy)
- Patient Action Plan (Care Management)
- Patient After-Visit Instructions (Dermatology)
- Patient After-Visit Summary (Acupuncture)
- Patient After-Visit Summary (Weight Management Plan)
- Patient Aftercare Instructions (Extraction/Wisdom Teeth)
- Patient Aftercare Instructions (Implant/Bone Graft)
- Patient Aftercare Instructions (Reflexology)
- Patient Discharge Instructions (Hospital After-Visit Summary)
- Patient Home Program Instructions (Biofeedback Therapy)
- Patient Instructions (Cardiology Care Plan)
- Patient Instructions (CBT Homework Plan/Review)
- Patient Instructions (Clear Aligners)
- Patient Instructions (ENT Post-Visit Summary)
- Patient Instructions (Fixed Appliances)
- Patient Instructions (Herbal Medicine Plan)
- Patient Instructions (Immunosuppression Safety & Monitoring)
- Patient Instructions (Integrative Lifestyle & Supplement Care Plan)
- Patient Instructions (Medical Weight Management Care Plan)
- Patient Instructions (OMT Aftercare and Home Exercise Program)
- Patient Instructions (Post-Cataract Surgery)
- Patient Instructions (Post-Craniotomy)
- Patient Instructions (Post-Spine Surgery)
- Patient Instructions (Postoperative Plastic Surgery)
- Patient Instructions (Radiation Therapy End-of-Treatment)
- Patient Instructions (Radiation Therapy Start-of-Treatment)
- Patient Instructions (Retainers)
- Patient Leisure/Home Program Instructions (Recreational Therapy)
- Patient Letter (Genetic Counseling Summary)
- Patient Nutrition Care Plan (After-Visit Summary)
- Patient-Friendly Results Letter (Neuropsychology)
- Patient/Caregiver Home Program & Education Plan (SLP)
- Patient/Caregiver Home Program Instructions (Horticultural Therapy)
- Patient/Caregiver Instructions (Animal-Assisted Therapy)
- Pediatric Suicide/Self-Harm Safety Plan
- Personalized Prevention Plan (AWV)
- Personalized Wellness Action Plan (Nutrition, Lifestyle, and Supplements)
- Post-Endoscopy Discharge Instructions (Pediatric)
- Postoperative Instructions (Pediatric Surgery)
- Pre-Procedure Supplement Hold Plan (Herbal Medicine)
- Radiation Safety Discharge Instructions (Therapeutic Radiopharmaceutical)
- Reiki Aftercare & Self-Practice Instructions
- Relapse Prevention Plan (SUD)
- Safety Plan (Stanley-Brown)
- School/Daycare Food Allergy Action Plan
- Seizure Action Plan (School)
- SMART Goal & Action Plan (Behavior Change)
- Specialty Lab Order & Kit Instructions (Functional Medicine)
Letter141
- Aeromedical Waiver Summary (Military)
- Aerospace Medicine Consultation/Referral Letter
- Appeal Letter (Anti-Obesity Medication Coverage Denial)
- Appeal Letter (Biologic/Targeted DMARD)
- Appeal Letter (Denied Cancer Therapy)
- Audiology Results Letter (Referring Clinician)
- Authorized Treatment Progress/Status Report (External Stakeholders)
- Behavioral Health Clinician-to-Clinician Referral & Care Coordination Letter
- Breast Pump DME/Insurance Letter
- Care Coordination Summary (Orthodontics, ENT, or Sleep Medicine)
- Cascade Testing Family Communication Letter
- Clinical Summary Letter (School/PCP)
- Colonoscopy Surveillance Interval Recommendation Note/Letter
- Complementary/Integrative Therapy Interprofessional Update Letter (To Referring Clinician)
- Consultation Letter (Pediatric Cardiology)
- Coordination Letter (General Dentist)
- Court Letter (Therapy Summary)
- Denial Appeal Letter (Medical Necessity)
- Disability/Leave Support Letter (Mental Health)
- DME Letter of Medical Necessity (PAP Device and Supplies)
- Driving Restriction/Medical Clearance Letter (Seizure)
- Durable Medical Equipment Medical Necessity Letter (Respiratory)
- Endoscopy Findings Summary Letter (Referring Clinician)
- Endoscopy/Pathology Results Communication Letter
- Expert Witness Report (Medical Opinion)
- FAA Special Issuance Support Letter (Clinician Summary)
- Functional Status Letter (Psychiatry)
- Higher Level of Care (PHP, IOP, Residential, or Inpatient) Medical Necessity Letter
- Insurance Narrative and Prior Authorization Request (Dental Procedure)
- Integrative Medicine Referral/Co-Management Letter (PCP or Specialist)
- Integrative/Functional Medicine Consultation Summary Letter (To Referring Clinician)
- Letter of Medical Necessity (AAC Device)
- Letter of Medical Necessity (Acupuncture)
- Letter of Medical Necessity (Adjunctive Experiential Therapies)
- Letter of Medical Necessity (Durable Medical Equipment/Assistive Devices)
- Letter of Medical Necessity (ENT Procedure/Imaging)
- Letter of Medical Necessity (Enteral Nutrition/Medical Foods)
- Letter of Medical Necessity (Genetic Testing)
- Letter of Medical Necessity (Metabolic/Bariatric Surgery)
- Letter of Medical Necessity (Myofunctional Therapy)
- Letter of Medical Necessity (Orthosis/Prosthesis)
- Letter of Medical Necessity (Psychotherapy)
- Letter of Medical Necessity (Supplement, Medical Food, or Integrative Therapy)
- Letter of Medical Necessity or Prior Authorization Request (Creative Arts Therapy)
- Letter to Referring Provider (Nutrition Consultation Summary)
- Level of Care/Services Authorization Request (SUD)
- Mammography Patient Lay Summary Letter (MQSA)
- Medical Necessity Letter (Anti-Obesity Medication)
- Medical Necessity Letter (Biofeedback Therapy)
- Medical Necessity Letter (Chiropractic Care)
- Medical Necessity Letter (Dialysis Supplies/Medications)
- Medical Necessity Letter (Growth Hormone Therapy)
- Medical Necessity Letter (Massage Therapy)
- Medical Necessity Letter (Medicare-Linked Dental Service)
- Medical Necessity Letter (Naturopathic Services)
- Medical Necessity Letter (Specialty Laboratory Testing)
- Medical Necessity Letter (Spinal Cord Stimulation)
- Medical Necessity Letter (Therapy Services and Supportive Equipment)
- Medical Necessity/Coverage Appeal Letter (Hypnotherapy)
- Medication Prior Authorization/Appeal Letter
- Neurology Consultation Letter (To Referring Clinician)
- Parenting Capacity Evaluation Report (Child Protection)
- Patient Letter (Genetic Counseling Summary)
- Pet Insurance Claim Letter (Medical Necessity)
- Physical Therapy Referral Letter & Rehabilitation Plan
- Plan of Care Transmission or Physician Update Letter (Physical Therapy)
- Preoperative Pulmonary Clearance Letter (Pediatric)
- Primary Care Referral/Consult Letter to Specialist
- Prior Authorization Request (Advanced Imaging)
- Prior Authorization Request (Allergen Immunotherapy)
- Prior Authorization Request (Anti-VEGF Medication)
- Prior Authorization Request (Antineoplastic Therapy)
- Prior Authorization Request (Aquatic Therapy)
- Prior Authorization Request (Biologic Therapy)
- Prior Authorization Request (Biologic/Targeted DMARD)
- Prior Authorization Request (Cardiology)
- Prior Authorization Request (Cervical Fusion)
- Prior Authorization Request (Dermatology Medication)
- Prior Authorization Request (Diabetes Technology)
- Prior Authorization Request (Endodontic Procedure)
- Prior Authorization Request (Endoscopy Procedure)
- Prior Authorization Request (Enteral Formula)
- Prior Authorization Request (IBD Biologic Therapy)
- Prior Authorization Request (Laboratory Test/Imaging)
- Prior Authorization Request (Medical/Support Services)
- Prior Authorization Request (Medication, Pediatric Nephrology)
- Prior Authorization Request (Medication)
- Prior Authorization Request (MOUD Medication)
- Prior Authorization Request (Ophthalmic Medication/Diagnostic Test)
- Prior Authorization Request (Orthognathic Surgery)
- Prior Authorization Request (Osteoporosis Medication)
- Prior Authorization Request (Pain Procedure)
- Prior Authorization Request (PET/CT)
- Prior Authorization Request (Proton Therapy)
- Prior Authorization Request (Psychological Testing)
- Prior Authorization Request (Psychotherapy)
- Prior Authorization Request (Rifaximin)
- Prior Authorization Request (Transplant Surgery)
- Prior Authorization Request (Urology Medication/Procedure)
- Prior Authorization Request (Wake-Promoting Medication)
- Prior Authorization Request Letter (Psychiatric Medication)
- Prior Authorization Request Letter (Severe Asthma Biologic Therapy)
- Prior Authorization/Appeal Letter (Osteopathic Manipulative Treatment)
- Prior Authorization/Medical Necessity Letter (Advanced Wound Therapies)
- Psychotherapy Progress Summary (Utilization/Medical Necessity)
- Psychotherapy Utilization Review/Medical Necessity Letter
- Referral Letter (Dental Specialist)
- Referral Letter (Higher Level of Care)
- Referral Letter (Ophthalmology/Medical Specialist)
- Referral Letter (Oral Surgery, Extractions, or Exposure)
- Referral Letter (Osteopathic Manipulative Medicine)
- Referral Letter (Pediatrics)
- Referral Letter (Sleep Surgery/ENT for OSA Alternatives)
- Referral Letter (Sports Medicine/Orthopedics)
- Referral Letter (To Dentist/Orthodontist)
- Referral Letter/Consult Summary (To Referring Provider)
- Referral/Consult Letter (Grief Counseling)
- Referral/Consult Summary Letter (Hematology to Referring Clinician)
- Referring Clinician Update Letter (Orthotics/Prosthetics)
- Referring Dentist Report (Endodontic Treatment Summary)
- Referring Provider Letter (Genetic Consultation Summary)
- Referring Provider Letter (Genetic Counseling Summary)
- Results Summary Letter (Referring Provider)
- Return-to-Learn/School Accommodation Letter (Concussion)
- Return-to-Play Mental Readiness Summary/Letter
- Return-to-Work/School Letter (Bereavement)
- School Accommodation/Support Letter (IEP/504)
- School Accommodations Letter (Pediatric Kidney Disease)
- School/Daycare Action Plan Letter (Chronic GI Condition)
- School/Daycare Letter (Return/Restrictions)
- Sports/Activity Clearance Letter (Pediatric Cardiology)
- Student Referral Letter (Specialty Consultation)
- Therapy Attendance Verification Letter
- Waitlist Status Notification Letter (Placement, Removal, or Not Listed)
- Work Status, FMLA, or Disability Letter (Rheumatic Disease)
- Work Status/Disability Letter (Neurosurgery)
- Work-Relatedness and Causation Narrative Report
- Work/Driving Safety Letter (Excessive Daytime Sleepiness)
- Work/School Accommodation Recommendation Letter
- Work/School Activity Restrictions and Modified Duty Letter
- Work/School Excuse Letter (Urgent Care)
Form78
- Adverse Event/Incident Report (Massage Therapy)
- Allergen Immunotherapy Extract Mixing Log
- Anesthesia Medical Direction Attestation (CMS 7 Requirements)
- Anesthesia Record (Perioperative)
- Anesthesia Time Documentation (Start/Stop, Relief, Interruptions)
- Animal-Assisted Therapy Incident/Safety Event Report
- Aromatherapy Intake & Safety Assessment
- ASAM Multidimensional Level-of-Care Assessment
- Autism Screening Documentation (Standardized Tool)
- Behavioral Health Screening Documentation (Pediatric)
- Behavioral Rating Scale Scoring Note
- Blend Formulation & Dispensing Record (Essential Oils)
- Blood Transfusion Administration & Reaction Monitoring Note
- Central Line Maintenance Note (Dressing Change/Line Assessment)
- Client Intake & Health History (Massage Therapy)
- Contraindications & Safety Screening (Reflexology)
- Controlled Substance Log Entry (Dispense/Administer)
- Couples/Family Intake Assessment (Relationship History)
- Critical/Panic Result Notification and Communication Note
- Delivery Room Resuscitation Note (NRP)
- Developmental Screening Documentation (Standardized Tool)
- Dispensing Record (Herbal Product)
- EMS Cardiac Arrest/Resuscitation Record
- EMS Chest Pain/ACS/STEMI Activation Note
- EMS Non-Transport/Refusal of Care Report
- EMS Patient Care Report (Non-Emergent Scheduled Transport)
- EMS Respiratory Distress Care Record
- Equine Therapy Safety Checklist/Risk Assessment (Per-Session)
- Evidence and Specimen Chain-of-Custody Log
- Fall/Incident Report (Home Health)
- Forensic Data/Discovery Packet Index
- Home Health Verbal/Telephone Order Documentation
- Home Program Adherence & Barrier Log (Myofunctional Therapy)
- Homeopathic Remedy Prescription Note
- Horticultural Therapy Safety Screening (Tools, Allergens, or Fall Risk)
- Hospice Election Statement Addendum (Non-Covered Items, Services, or Drugs)
- Hypnotherapy Intake Assessment
- Immunization Administration Note
- Incident/Adverse Event Report (Reflexology)
- Initial Intake & Consent (Reiki)
- Injury Incident Report (Emergency/EMS Activation)
- IRF Preadmission Screening Summary
- Leisure Interest Inventory (Recreational Therapy)
- Mandated Report Documentation (Child Abuse/Neglect)
- Medicare Coverage Documentation (Acupuncture for Chronic Low Back Pain)
- Medicare Direct Access Attestation (Audiology AB Modifier)
- Medication Reconciliation Note (OTC and Supplement/Herbal Products)
- MNT Billing Attestation (Time/Units & Referral)
- Modalities Treatment Note (Hot/Cold, E-Stim, Ultrasound, Whirlpool)
- Moderate Sedation Record (GI Endoscopy)
- Movement Assessment (Dance/Movement Therapy)
- Nitrous Oxide Sedation Record
- Nursing Admission Assessment (Inpatient)
- OASIS Recertification/60-Day Reassessment
- OASIS Resumption of Care Comprehensive Assessment (ROC)
- OASIS Start of Care Comprehensive Assessment (SOC)
- Office-Based Sedation/Anesthesia Record
- Outcome Measures Flowsheet (Yoga Therapy)
- Patient-Ventilator Assessment Note
- Point-of-Care Glucose Check & Hypoglycemia Treatment Note
- Pool Safety Screening Note (Aquatic Therapy)
- Radiopharmaceutical Administration Record (Diagnostic)
- Reflexology Intake Assessment (Initial Visit)
- Respirator Fit Test Record (QLFT/QNFT)
- Restraint/Seclusion Initiation & Monitoring Note
- Risk Assessment and Safety Plan (Older Adult)
- Sharps Injury/Exposure Incident Report (Clinic Safety)
- Student Handoff Note (I-PASS)
- Subpoena/Court Order Response & Records Release Log
- Substance Use Disorder Intake Assessment
- Teacher/Staff Interview Summary (Evaluation)
- Test Administration/Scoring Log (Psychological/Neuropsychological)
- Therapy Animal Health & Welfare Log (Animal/Handler)
- Therapy Animal Suitability & Contraindication Screening (Patient)
- Therapy Animal Team Visit Log (Facility-Based)
- Time Log & Billing Attestation (Neuropsychological Services)
- Vision Screening Documentation
- Wellness Program Intake Assessment (HRA/Whole-Person)
Request39
- Ambulance Medical Necessity & Billing Documentation Summary (Medicare)
- DME/Orthotics Order Note
- Home Health Certification Face-to-Face Narrative
- Home Health Wound Care Referral/Orders
- Home Oxygen Qualification & Prescription Note (Medicare)
- Medical Necessity Addendum (IMRT)
- Prior Authorization Request (Acupuncture Services)
- Prior Authorization Request (Advanced Imaging)
- Prior Authorization Request (Anti-Obesity Medication)
- Prior Authorization Request (Antineoplastic Therapy)
- Prior Authorization Request (Antiseizure Medication)
- Prior Authorization Request (Art Therapy)
- Prior Authorization Request (Behavioral Health Services)
- Prior Authorization Request (Biofeedback Therapy)
- Prior Authorization Request (Diabetes Device/Supplies)
- Prior Authorization Request (Diagnostic Test)
- Prior Authorization Request (DMEPOS Orthoses/Prosthetics)
- Prior Authorization Request (Equine Therapy)
- Prior Authorization Request (Genetic Test)
- Prior Authorization Request (Hematology Medication)
- Prior Authorization Request (Hepatitis C Direct-Acting Antiviral)
- Prior Authorization Request (IBD Biologic/Small-Molecule Therapy)
- Prior Authorization Request (Imaging/DME)
- Prior Authorization Request (Lumbar Fusion)
- Prior Authorization Request (Music Therapy)
- Prior Authorization Request (Neuropsychological Testing)
- Prior Authorization Request (Nutrition Therapy Services)
- Prior Authorization Request (Occupational Therapy Services)
- Prior Authorization Request (Orthodontic Treatment)
- Prior Authorization Request (Outpatient SLP Therapy)
- Prior Authorization Request (Panniculectomy)
- Prior Authorization Request (Physical Therapy Services)
- Prior Authorization Request (Reduction Mammaplasty)
- Prior Authorization Request (Surgery/Procedure)
- Sleep Study Order Note (PSG/HSAT Medical Necessity)
- Standard Written Order (DMEPOS)
- Superbill/Invoice (Complementary & Integrative Medicine Visit)
- Therapeutic Shoes/Inserts Documentation (Diabetes)
- Treating Physician Status Report Request (FAA)
Consent13
- Consent & Media/Artifact Handling Note (Drama Therapy)
- Informed Consent (Ayurveda Procedure)
- Informed Consent & Disclosure (Clinical Hypnosis)
- Informed Consent & Scope-of-Practice Statement (Reflexology)
- Informed Consent Documentation Note (Aesthetic Procedures)
- Informed Consent Note (Aromatherapy)
- Informed Consent Note (Procedure/Anesthesia)
- Informed Consent/Disclosure (Homeopathy Services)
- Informed Consent/Notice of Forensic Services (Adult)
- Informed Consent/Notice of Forensic Services (Minor/Guardian)
- Release of Information & Interprofessional Communication (Reflexology)
- Release of Information Authorization (42 CFR Part 2)
- Systemic Therapy Consent Note (Chemotherapy/Immunotherapy)
Agreement3
Certificate11
- Aeromedical Status Report (Obstructive Sleep Apnea)
- Disability/FMLA Certification
- Fitness-for-Duty Evaluation Report
- Hospice Physician Certification of Terminal Illness (Initial)
- OSHA Medical Surveillance Written Medical Opinion (Employer/Employee)
- Respirator Medical Clearance Certificate
- Return-to-Sport/Activity Clearance Note (Non-Concussion Musculoskeletal)
- Sports Participation Clearance Letter
- Superbill/Receipt (Homeopathy Visit)
- Vision Certification Form (DMV/School/Work)
- Work Restrictions/Return-to-Work Note
EHR Integrations401 pages
EHR Systems346
- Abbott Informatics STARLIMS
- Abbott LibreView
- Abox
- Accenture IHE
- Acumen 2.0
- Acumen EHR
- Ada Health (Symptom Assessment)
- Agfa Healthcare ORBIS
- AGFA IMPAX
- ALERT
- AliveCor Kardia
- AllegianceMD
- Allergy EHR
- Allscripts CareInMotion
- Alma Clinica
- Amazing Charts
- Amazon HealthLake
- American Well (Telehealth)
- AMS Ultra Charts
- Amwell
- Apple HealthKit
- Aprima
- Aprima EHR
- Arcadia (Population Health)
- Athenahealth
- Athenahealth athenaClinicals
- Azalea Health
- Babylon Health
- Bahmni
- Benchmark Systems
- Bizmatics PrognoCIS
- BlueEHS
- Buoy Health
- Calm Health
- Cambio COSMIC
- CancerIQ
- CareConnect (NHS England)
- CareCredit
- Carestream Dental
- Carestream Vue RIS
- Cedar
- CentralReach (ABA therapy)
- Cerbo
- Cerner
- Cerner HealtheIntent
- Cerner Millennium
- Cerner PathNet (Laboratory)
- Cerner Patient Portal
- Cerner Powerchart
- CGM CLINICAL
- Change Healthcare Cardiology
- Charm EHR
- Charm Health EHR
- CharmHealth
- ChartLogic
- ChipSoft
- ChiroTouch
- Claimocity
- ClinicalWorks
- Clinicient Insight
- Cliniko
- Cloud9
- Clue (Women's Health)
- CommCare
- CompuGroup Medical (CGM)
- Compulink Healthcare Solutions
- CoreDental
- Coreplus
- Credible Behavioral Health
- CrisSoft
- CureMD Oncology
- Curve Dental
- Daiwabo Information System
- Dedalus
- Dentrix
- Dexcom Clarity
- DGL Software
- DHIS2
- DigiDoc
- Dimagi
- DIPS
- Docman
- DocStarEMR
- Doctor On Demand
- Doctoralia
- DoctorGESTION
- DocuTAP
- DoD AHLTA
- Dovetail
- Doxy.me
- Dr.JBP
- DrChrono
- DuxWare
- DXC Lorenzo
- Eaglesoft
- eCare NEXT
- eCareSoft
- eClincialWorks V11
- eClinicalWorks
- eHealth Saskatchewan
- Elation
- Elekta MOSAIQ (Oncology)
- Elixir
- Elsevier Care Planning
- eMDs
- EncounterPRO
- Enovacom
- Epic
- Epic Beaker (Laboratory)
- Epic Cupid (Cardiology)
- Epic Healthy Planet
- EpicCare Link
- ESO suite
- Evident (CPSI)
- Exym
- Eyefinity
- Falcon EHR
- Fitbit Health Solutions
- Flo Health
- FollowMyHealth (Allscripts)
- Fujifilm Synapse PACS
- Fujitsu HOPE
- Garmin Connect
- GE Centricity PACS
- GE Healthcare Muse (Cardiology)
- GEMMS ONE
- Genie
- Gensolve
- GetWellNetwork
- Glooko (Diabetes)
- GoodMD
- Google Cloud Healthcare API
- Google Fit
- GP2GP (UK)
- Greenway Health
- Halaxy
- HarmoniMD
- Harris CareTracker
- Harris Healthcare
- Headspace Health
- Healow (eClinicalWorks)
- Health Catalyst (Analytics)
- Health Gorilla
- Health Metrics
- HealthEC (Population Health)
- HealthFusion MediTouch
- Healthie
- Healthland (CPSI)
- HealthPac
- HealthPAC Office
- HealthVoyager
- Heliant
- Hello Health
- Henry Schein MicroMD
- HiDoctor
- HiEHR
- HIM SA
- Hospira
- i-MED
- i.s.h.med (SAP/Cerner)
- IBM Watson Health
- iCare
- ID (France)
- iKnowMed
- Indra Health
- Infermedica
- Innovaccer (Population Health)
- InstaMed
- InSync Healthcare Solutions
- Integrity EMR for Eyes
- InterSystems TrakCare
- Intrahealth Profile
- iPatientCare
- iSalus Healthcare
- iSOFT
- Jamf Healthcare Listener
- JgpGrams
- K Health
- kalix
- KLAS Clinical Solutions
- KP Health Connect
- Kry/Livi (Europe)
- Kyruus
- LG CNS
- Livongo
- Lorenzo (DXC Technology)
- LSS Data Systems
- Luma Health
- MacPractice
- McKesson Cardiology
- MD Connection
- MDLand
- MDLive
- MDVita
- Medasys
- MedAZ
- Meddbase
- MedEZ
- MEDHOST
- Medical Mastermind
- Medical Office Online
- Medilink
- MedInformatix
- MEDITECH Laboratory
- Medtech NZ
- Medtronic CareLink
- Merge Cardio (IBM)
- Merge PACS (IBM)
- METAVISION
- Mettles
- MHS GENESIS
- MicroMD
- Microsoft Cloud for Healthcare
- Microtest Evolution
- Mindstrong Health
- Modernizing Medicine (EMA)
- MTBC
- MV Sistemas
- My MEDITECH
- MyChart (Epic patient portal)
- mySugr (Diabetes)
- Napier Healthcare
- Natural Cycles
- Net Health
- Netsmart
- Neusoft
- Nexgen
- Nextech
- NexTech
- NextGen Healthcare
- NextGen Patient Portal
- Nexus
- NHS Spine
- NovaBiomedical
- NueMD
- OdysseyEMR
- Office Practicum
- Omada Health (Chronic Disease)
- OneTouch Reveal
- OnPatient
- OpenEMR
- OpenMRS
- Optum Physician EMR
- OptumCare
- Orchard Harvest LIS
- Orion Health
- PAMUS
- Paragon
- Patientco
- PatientNow
- PatientOS
- PatientPay
- PatientPop
- PCC (Pediatric)
- PDOCs
- Philips IntelliSpace Cardiovascular
- Philips IntelliSpace PACS
- Philips Tasy EMR
- Philips Wellcentive
- Phreesia
- PointClickCare
- Portavita
- Power Diary
- Practice Mate
- PracticeSuite
- Practo Ray
- Prevail Health
- Primary Health Care Information System (PHCIS)
- Prime Suite
- PrognoCIS
- Propeller Health (Respiratory)
- PulseEHR
- Push Doctor (UK)
- QHR Technologies
- QuadraMed QCPR
- Qualifacts
- RapidPro
- RaySearch RayCare (Oncology)
- Rectangle Health
- RelayHealth
- ReLi Med Solutions
- RevolutionEHR (optometry)
- Riomed
- RXNT
- Sammy EHR
- Samsung Health
- SAP for Healthcare
- SCC Soft Computer (Laboratory)
- Sectra PACS & RIS
- SequelMed
- Siemens Healthineers syngo
- Siemens Soarian
- SIGSAÚDE
- SilverCloud Health
- Simplee
- SimplePractice
- SmartCare (Zambia)
- Soarian Clinicals
- Socrates
- Software of Excellence - EXACT
- SOLAR
- SONDA Salud
- SRS Health
- Stratus EHR
- StringSoft
- Sunquest Laboratory
- Sunrise Clinical Manager
- Sympto (Women's Health)
- T-System
- Tebra
- Teladoc Health
- Theranest
- TI Saúde
- TIE Healthcare
- Tieto Health
- TietoEVRY
- TM3
- TotalMD
- Touchworks EHR
- TrakCare (InterSystems)
- Valant
- Valence Health
- VAMS (Veterans Affairs)
- Varian Aria (Oncology)
- Vesalius
- Virence Health
- Vision (INPS) - UK primary care
- VistA
- VISUS
- VSee (Telehealth)
- Waiting Room Solutions
- WebPT
- Welligent
- WellSky
- Winning Health
- Withings Health Mate
- Woebot Health
- Wolters Kluwer
- WRS Health
- Xchart
- YiDu Cloud
- Your.MD
- ZH Healthcare
- Zocdoc
- Zoom for Healthcare
- ZoomCare
EMR Systems39
- Aarogya
- Accuro
- AdvancedMD
- Al Tibbi
- Alfa
- Best Practice Software
- Bizmatics
- CureMD
- DataMed
- DiaMed
- DocPlanner
- Doctena
- EMIS Health
- GE HealthCare
- GoodX Web
- Health One (MedEMass)
- HealthPlix
- Healthquest EMR
- iMeddoc
- Jane
- Lightning Step
- Lybrate
- Medeil
- MEDITECH
- MocDoc HMS
- Oracle Health
- Oscar Pro
- Practice Fusion
- Practice Perfect
- PracticePal
- Praxis
- SoftClinic
- SystmOne (by TPP)
- Telus - MedAccess
- Telus Practice Solution EMR
- TherapyNotes
- TPP
- veradigm
- WELL Health Technologies
Practice Management Systems12
ICD-10 Code Library1,918 pages
Certain Infectious and Parasitic Diseases (A00–B99)167
- A00 — Cholera
- A01 — Typhoid and paratyphoid fevers
- A02 — Other salmonella infections
- A03 — Shigellosis
- A04 — Other bacterial intestinal infections
- A05 — Other bacterial foodborne intoxications, not elsewhere classified
- A06 — Amebiasis
- A07 — Other protozoal intestinal diseases
- A08 — Viral and other specified intestinal infections
- A09 — Infectious gastroenteritis and colitis, unspecified
- A15 — Respiratory tuberculosis
- A17 — Tuberculosis of nervous system
- A18 — Tuberculosis of other organs
- A19 — Miliary tuberculosis
- A20 — Plague
- A21 — Tularemia
- A22 — Anthrax
- A23 — Brucellosis
- A24 — Glanders and melioidosis
- A25 — Rat-bite fevers
- A26 — Erysipeloid
- A27 — Leptospirosis
- A28 — Other zoonotic bacterial diseases, not elsewhere classified
- A30 — Leprosy [Hansen's disease]
- A31 — Infection due to other mycobacteria
- A32 — Listeriosis
- A33 — Tetanus neonatorum
- A34 — Obstetrical tetanus
- A35 — Other tetanus
- A36 — Diphtheria
- A37 — Whooping cough
- A38 — Scarlet fever
- A39 — Meningococcal infection
- A40 — Streptococcal sepsis
- A41 — Other sepsis
- A42 — Actinomycosis
- A43 — Nocardiosis
- A44 — Bartonellosis
- A46 — Erysipelas
- A48 — Other bacterial diseases, not elsewhere classified
- A49 — Bacterial infection of unspecified site
- A50 — Congenital syphilis
- A51 — Early syphilis
- A52 — Late syphilis
- A53 — Other and unspecified syphilis
- A54 — Gonococcal infection
- A55 — Chlamydial lymphogranuloma (venereum)
- A56 — Other sexually transmitted chlamydial diseases
- A57 — Chancroid
- A58 — Granuloma inguinale
- A59 — Trichomoniasis
- A60 — Anogenital herpesviral [herpes simplex] infections
- A63 — Other predominantly sexually transmitted diseases, not elsewhere classified
- A64 — Unspecified sexually transmitted disease
- A65 — Nonvenereal syphilis
- A66 — Yaws
- A67 — Pinta [carate]
- A68 — Relapsing fevers
- A69 — Other spirochetal infections
- A70 — Chlamydia psittaci infections
- A71 — Trachoma
- A74 — Other diseases caused by chlamydiae
- A75 — Typhus fever
- A77 — Spotted fever [tick-borne rickettsioses]
- A78 — Q fever
- A79 — Other rickettsioses
- A80 — Acute poliomyelitis
- A81 — Atypical virus infections of central nervous system
- A82 — Rabies
- A83 — Mosquito-borne viral encephalitis
- A84 — Tick-borne viral encephalitis
- A85 — Other viral encephalitis, not elsewhere classified
- A86 — Unspecified viral encephalitis
- A87 — Viral meningitis
- A88 — Other viral infections of central nervous system, not elsewhere classified
- A89 — Unspecified viral infection of central nervous system
- A90 — Dengue fever [classical dengue]
- A91 — Dengue hemorrhagic fever
- A92 — Other mosquito-borne viral fevers
- A93 — Other arthropod-borne viral fevers, not elsewhere classified
- A94 — Unspecified arthropod-borne viral fever
- A95 — Yellow fever
- A96 — Arenaviral hemorrhagic fever
- A98 — Other viral hemorrhagic fevers, not elsewhere classified
- A99 — Unspecified viral hemorrhagic fever
- B00 — Herpesviral [herpes simplex] infections
- B01 — Varicella [chickenpox]
- B02 — Zoster [herpes zoster]
- B03 — Smallpox
- B04 — Monkeypox
- B05 — Measles
- B06 — Rubella [German measles]
- B07 — Viral warts
- B08 — Other viral infections characterized by skin and mucous membrane lesions, not elsewhere classified
- B09 — Unspecified viral infection characterized by skin and mucous membrane lesions
- B10 — Other human herpesviruses
- B15 — Acute hepatitis A
- B16 — Acute hepatitis B
- B17 — Other acute viral hepatitis
- B18 — Chronic viral hepatitis
- B19 — Unspecified viral hepatitis
- B20 — Human immunodeficiency virus [HIV] disease
- B25 — Cytomegaloviral disease
- B26 — Mumps
- B27 — Infectious mononucleosis
- B30 — Viral conjunctivitis
- B33 — Other viral diseases, not elsewhere classified
- B34 — Viral infection of unspecified site
- B35 — Dermatophytosis
- B36 — Other superficial mycoses
- B37 — Candidiasis
- B38 — Coccidioidomycosis
- B39 — Histoplasmosis
- B40 — Blastomycosis
- B41 — Paracoccidioidomycosis
- B42 — Sporotrichosis
- B43 — Chromomycosis and pheomycotic abscess
- B44 — Aspergillosis
- B45 — Cryptococcosis
- B46 — Zygomycosis
- B47 — Mycetoma
- B48 — Other mycoses, not elsewhere classified
- B49 — Unspecified mycosis
- B50 — Plasmodium falciparum malaria
- B51 — Plasmodium vivax malaria
- B52 — Plasmodium malariae malaria
- B53 — Other specified malaria
- B54 — Unspecified malaria
- B55 — Leishmaniasis
- B56 — African trypanosomiasis
- B57 — Chagas' disease
- B58 — Toxoplasmosis
- B59 — Pneumocystosis
- B60 — Other protozoal diseases, not elsewhere classified
- B64 — Unspecified protozoal disease
- B65 — Schistosomiasis [bilharziasis]
- B66 — Other fluke infections
- B67 — Echinococcosis
- B68 — Taeniasis
- B69 — Cysticercosis
- B70 — Diphyllobothriasis and sparganosis
- B71 — Other cestode infections
- B72 — Dracunculiasis
- B73 — Onchocerciasis
- B74 — Filariasis
- B75 — Trichinellosis
- B76 — Hookworm diseases
- B77 — Ascariasis
- B78 — Strongyloidiasis
- B79 — Trichuriasis
- B80 — Enterobiasis
- B81 — Other intestinal helminthiases, not elsewhere classified
- B82 — Unspecified intestinal parasitism
- B83 — Other helminthiases
- B85 — Pediculosis and phthiriasis
- B86 — Scabies
- B87 — Myiasis
- B88 — Other infestations
- B89 — Unspecified parasitic disease
- B90 — Sequelae of tuberculosis
- B91 — Sequelae of poliomyelitis
- B92 — Sequelae of leprosy
- B94 — Sequelae of other and unspecified infectious and parasitic diseases
- B95 — Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere
- B96 — Other bacterial agents as the cause of diseases classified elsewhere
- B97 — Viral agents as the cause of diseases classified elsewhere
- B99 — Other and unspecified infectious diseases
Neoplasms (C00–D49)141
- C00 — Malignant neoplasm of lip
- C01 — Malignant neoplasm of base of tongue
- C02 — Malignant neoplasm of other and unspecified parts of tongue
- C03 — Malignant neoplasm of gum
- C04 — Malignant neoplasm of floor of mouth
- C4A — Merkel cell carcinoma
- C05 — Malignant neoplasm of palate
- C06 — Malignant neoplasm of other and unspecified parts of mouth
- C07 — Malignant neoplasm of parotid gland
- C7A — Malignant neuroendocrine tumors
- C7B — Secondary neuroendocrine tumors
- C08 — Malignant neoplasm of other and unspecified major salivary glands
- C09 — Malignant neoplasm of tonsil
- C10 — Malignant neoplasm of oropharynx
- C11 — Malignant neoplasm of nasopharynx
- C12 — Malignant neoplasm of pyriform sinus
- C13 — Malignant neoplasm of hypopharynx
- C14 — Malignant neoplasm of other and ill-defined sites in the lip, oral cavity and pharynx
- C15 — Malignant neoplasm of esophagus
- C16 — Malignant neoplasm of stomach
- C17 — Malignant neoplasm of small intestine
- C18 — Malignant neoplasm of colon
- C19 — Malignant neoplasm of rectosigmoid junction
- C20 — Malignant neoplasm of rectum
- C21 — Malignant neoplasm of anus and anal canal
- C22 — Malignant neoplasm of liver and intrahepatic bile ducts
- C23 — Malignant neoplasm of gallbladder
- C24 — Malignant neoplasm of other and unspecified parts of biliary tract
- C25 — Malignant neoplasm of pancreas
- C26 — Malignant neoplasm of other and ill-defined digestive organs
- C30 — Malignant neoplasm of nasal cavity and middle ear
- C31 — Malignant neoplasm of accessory sinuses
- C32 — Malignant neoplasm of larynx
- C33 — Malignant neoplasm of trachea
- C34 — Malignant neoplasm of bronchus and lung
- C37 — Malignant neoplasm of thymus
- C38 — Malignant neoplasm of heart, mediastinum and pleura
- C39 — Malignant neoplasm of other and ill-defined sites in the respiratory system and intrathoracic organs
- C40 — Malignant neoplasm of bone and articular cartilage of limbs
- C41 — Malignant neoplasm of bone and articular cartilage of other and unspecified sites
- C43 — Malignant melanoma of skin
- C44 — Other and unspecified malignant neoplasm of skin
- C45 — Mesothelioma
- C46 — Kaposi's sarcoma
- C47 — Malignant neoplasm of peripheral nerves and autonomic nervous system
- C48 — Malignant neoplasm of retroperitoneum and peritoneum
- C49 — Malignant neoplasm of other connective and soft tissue
- C50 — Malignant neoplasm of breast
- C51 — Malignant neoplasm of vulva
- C52 — Malignant neoplasm of vagina
- C53 — Malignant neoplasm of cervix uteri
- C54 — Malignant neoplasm of corpus uteri
- C55 — Malignant neoplasm of uterus, part unspecified
- C56 — Malignant neoplasm of ovary
- C57 — Malignant neoplasm of other and unspecified female genital organs
- C58 — Malignant neoplasm of placenta
- C60 — Malignant neoplasm of penis
- C61 — Malignant neoplasm of prostate
- C62 — Malignant neoplasm of testis
- C63 — Malignant neoplasm of other and unspecified male genital organs
- C64 — Malignant neoplasm of kidney, except renal pelvis
- C65 — Malignant neoplasm of renal pelvis
- C66 — Malignant neoplasm of ureter
- C67 — Malignant neoplasm of bladder
- C68 — Malignant neoplasm of other and unspecified urinary organs
- C69 — Malignant neoplasm of eye and adnexa
- C70 — Malignant neoplasm of meninges
- C71 — Malignant neoplasm of brain
- C72 — Malignant neoplasm of spinal cord, cranial nerves and other parts of central nervous system
- C73 — Malignant neoplasm of thyroid gland
- C74 — Malignant neoplasm of adrenal gland
- C75 — Malignant neoplasm of other endocrine glands and related structures
- C76 — Malignant neoplasm of other and ill-defined sites
- C77 — Secondary and unspecified malignant neoplasm of lymph nodes
- C78 — Secondary malignant neoplasm of respiratory and digestive organs
- C79 — Secondary malignant neoplasm of other and unspecified sites
- C80 — Malignant neoplasm without specification of site
- C81 — Hodgkin lymphoma
- C82 — Follicular lymphoma
- C83 — Non-follicular lymphoma
- C84 — Mature T/NK-cell lymphomas
- C85 — Other specified and unspecified types of non-Hodgkin lymphoma
- C86 — Other specified types of T/NK-cell lymphoma
- C88 — Malignant immunoproliferative diseases and certain other B-cell lymphomas
- C90 — Multiple myeloma and malignant plasma cell neoplasms
- C91 — Lymphoid leukemia
- C92 — Myeloid leukemia
- C93 — Monocytic leukemia
- C94 — Other leukemias of specified cell type
- C95 — Leukemia of unspecified cell type
- C96 — Other and unspecified malignant neoplasms of lymphoid, hematopoietic and related tissue
- D00 — Carcinoma in situ of oral cavity, esophagus and stomach
- D01 — Carcinoma in situ of other and unspecified digestive organs
- D02 — Carcinoma in situ of middle ear and respiratory system
- D03 — Melanoma in situ
- D3A — Benign neuroendocrine tumors
- D04 — Carcinoma in situ of skin
- D05 — Carcinoma in situ of breast
- D06 — Carcinoma in situ of cervix uteri
- D07 — Carcinoma in situ of other and unspecified genital organs
- D09 — Carcinoma in situ of other and unspecified sites
- D10 — Benign neoplasm of mouth and pharynx
- D11 — Benign neoplasm of major salivary glands
- D12 — Benign neoplasm of colon, rectum, anus and anal canal
- D13 — Benign neoplasm of other and ill-defined parts of digestive system
- D14 — Benign neoplasm of middle ear and respiratory system
- D15 — Benign neoplasm of other and unspecified intrathoracic organs
- D16 — Benign neoplasm of bone and articular cartilage
- D17 — Benign lipomatous neoplasm
- D18 — Hemangioma and lymphangioma, any site
- D19 — Benign neoplasm of mesothelial tissue
- D20 — Benign neoplasm of soft tissue of retroperitoneum and peritoneum
- D21 — Other benign neoplasms of connective and other soft tissue
- D22 — Melanocytic nevi
- D23 — Other benign neoplasms of skin
- D24 — Benign neoplasm of breast
- D25 — Leiomyoma of uterus
- D26 — Other benign neoplasms of uterus
- D27 — Benign neoplasm of ovary
- D28 — Benign neoplasm of other and unspecified female genital organs
- D29 — Benign neoplasm of male genital organs
- D30 — Benign neoplasm of urinary organs
- D31 — Benign neoplasm of eye and adnexa
- D32 — Benign neoplasm of meninges
- D33 — Benign neoplasm of brain and other parts of central nervous system
- D34 — Benign neoplasm of thyroid gland
- D35 — Benign neoplasm of other and unspecified endocrine glands
- D36 — Benign neoplasm of other and unspecified sites
- D37 — Neoplasm of uncertain behavior of oral cavity and digestive organs
- D38 — Neoplasm of uncertain behavior of middle ear and respiratory and intrathoracic organs
- D39 — Neoplasm of uncertain behavior of female genital organs
- D40 — Neoplasm of uncertain behavior of male genital organs
- D41 — Neoplasm of uncertain behavior of urinary organs
- D42 — Neoplasm of uncertain behavior of meninges
- D43 — Neoplasm of uncertain behavior of brain and central nervous system
- D44 — Neoplasm of uncertain behavior of endocrine glands
- D45 — Polycythemia vera
- D46 — Myelodysplastic syndromes
- D47 — Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
- D48 — Neoplasm of uncertain behavior of other and unspecified sites
- D49 — Neoplasms of unspecified behavior
Blood & Blood-forming Organs (D50–D89)31
- D55 — Anemia due to enzyme disorders
- D56 — Thalassemia
- D57 — Sickle-cell disorders
- D58 — Other hereditary hemolytic anemias
- D59 — Acquired hemolytic anemia
- D60 — Acquired pure red cell aplasia [erythroblastopenia]
- D61 — Other aplastic anemias and other bone marrow failure syndromes
- D62 — Acute posthemorrhagic anemia
- D63 — Anemia in chronic diseases classified elsewhere
- D64 — Other anemias
- D65 — Disseminated intravascular coagulation [defibrination syndrome]
- D66 — Hereditary factor VIII deficiency
- D67 — Hereditary factor IX deficiency
- D68 — Other coagulation defects
- D69 — Purpura and other hemorrhagic conditions
- D70 — Neutropenia
- D71 — Functional disorders of polymorphonuclear neutrophils
- D72 — Other disorders of white blood cells
- D73 — Diseases of spleen
- D74 — Methemoglobinemia
- D75 — Other and unspecified diseases of blood and blood-forming organs
- D76 — Other specified diseases with participation of lymphoreticular and reticulohistiocytic tissue
- D77 — Other disorders of blood and blood-forming organs in diseases classified elsewhere
- D78 — Intraoperative and postprocedural complications of the spleen
- D80 — Immunodeficiency with predominantly antibody defects
- D81 — Combined immunodeficiencies
- D82 — Immunodeficiency associated with other major defects
- D83 — Common variable immunodeficiency
- D84 — Other immunodeficiencies
- D86 — Sarcoidosis
- D89 — Other disorders involving the immune mechanism, not elsewhere classified
Endocrine, Nutritional & Metabolic (E00–E89)73
- E00 — Congenital iodine-deficiency syndrome
- E01 — Iodine-deficiency related thyroid disorders and allied conditions
- E02 — Subclinical iodine-deficiency hypothyroidism
- E03 — Other hypothyroidism
- E04 — Other nontoxic goiter
- E05 — Thyrotoxicosis [hyperthyroidism]
- E06 — Thyroiditis
- E07 — Other disorders of thyroid
- E08 — Diabetes mellitus due to underlying condition
- E09 — Drug or chemical induced diabetes mellitus
- E10 — Type 1 diabetes mellitus
- E11 — Type 2 diabetes mellitus
- E13 — Other specified diabetes mellitus
- E15 — Nondiabetic hypoglycemic coma
- E16 — Other disorders of pancreatic internal secretion
- E20 — Hypoparathyroidism
- E21 — Hyperparathyroidism and other disorders of parathyroid gland
- E22 — Hyperfunction of pituitary gland
- E23 — Hypofunction and other disorders of the pituitary gland
- E24 — Cushing's syndrome
- E25 — Adrenogenital disorders
- E26 — Hyperaldosteronism
- E27 — Other disorders of adrenal gland
- E28 — Ovarian dysfunction
- E29 — Testicular dysfunction
- E30 — Disorders of puberty, not elsewhere classified
- E31 — Polyglandular dysfunction
- E32 — Diseases of thymus
- E34 — Other endocrine disorders
- E35 — Disorders of endocrine glands in diseases classified elsewhere
- E36 — Intraoperative complications of endocrine system
- E40 — Kwashiorkor
- E41 — Nutritional marasmus
- E42 — Marasmic kwashiorkor
- E43 — Unspecified severe protein-calorie malnutrition
- E44 — Protein-calorie malnutrition of moderate and mild degree
- E45 — Retarded development following protein-calorie malnutrition
- E46 — Unspecified protein-calorie malnutrition
- E50 — Vitamin A deficiency
- E51 — Thiamine deficiency
- E52 — Niacin deficiency [pellagra]
- E53 — Deficiency of other B group vitamins
- E54 — Ascorbic acid deficiency
- E55 — Vitamin D deficiency
- E56 — Other vitamin deficiencies
- E58 — Dietary calcium deficiency
- E59 — Dietary selenium deficiency
- E60 — Dietary zinc deficiency
- E61 — Deficiency of other nutrient elements
- E63 — Other nutritional deficiencies
- E64 — Sequelae of malnutrition and other nutritional deficiencies
- E65 — Localized adiposity
- E66 — Overweight and obesity
- E67 — Other hyperalimentation
- E68 — Sequelae of hyperalimentation
- E70 — Disorders of aromatic amino-acid metabolism
- E71 — Disorders of branched-chain amino-acid metabolism and fatty-acid metabolism
- E72 — Other disorders of amino-acid metabolism
- E73 — Lactose intolerance
- E74 — Other disorders of carbohydrate metabolism
- E75 — Disorders of sphingolipid metabolism and other lipid storage disorders
- E76 — Disorders of glycosaminoglycan metabolism
- E77 — Disorders of glycoprotein metabolism
- E78 — Disorders of lipoprotein metabolism and other lipidemias
- E79 — Disorders of purine and pyrimidine metabolism
- E80 — Disorders of porphyrin and bilirubin metabolism
- E83 — Disorders of mineral metabolism
- E84 — Cystic fibrosis
- E85 — Amyloidosis
- E86 — Volume depletion
- E87 — Other disorders of fluid, electrolyte and acid-base balance
- E88 — Other and unspecified metabolic disorders
- E89 — Postprocedural endocrine and metabolic complications and disorders, not elsewhere classified
Mental, Behavioral & Neurodevelopmental (F01–F99)72
- F01 — Vascular dementia
- F02 — Dementia in other diseases classified elsewhere
- F03 — Unspecified dementia
- F04 — Amnestic disorder due to known physiological condition
- F05 — Delirium due to known physiological condition
- F06 — Other mental disorders due to known physiological condition
- F07 — Personality and behavioral disorders due to known physiological condition
- F09 — Unspecified mental disorder due to known physiological condition
- F10 — Alcohol related disorders
- F11 — Opioid related disorders
- F12 — Cannabis related disorders
- F13 — Sedative, hypnotic, or anxiolytic related disorders
- F14 — Cocaine related disorders
- F15 — Other stimulant related disorders
- F16 — Hallucinogen related disorders
- F17 — Nicotine dependence
- F18 — Inhalant related disorders
- F19 — Other psychoactive substance related disorders
- F20 — Schizophrenia
- F21 — Schizotypal disorder
- F22 — Delusional disorders
- F23 — Brief psychotic disorder
- F24 — Shared psychotic disorder
- F25 — Schizoaffective disorders
- F28 — Other psychotic disorder not due to a substance or known physiological condition
- F29 — Unspecified psychosis not due to a substance or known physiological condition
- F30 — Manic episode
- F31 — Bipolar disorder
- F32 — Depressive episode
- F33 — Major depressive disorder, recurrent
- F34 — Persistent mood [affective] disorders
- F39 — Unspecified mood [affective] disorder
- F40 — Phobic anxiety disorders
- F41 — Other anxiety disorders
- F42 — Obsessive-compulsive disorder
- F43 — Reaction to severe stress, and adjustment disorders
- F44 — Dissociative and conversion disorders
- F45 — Somatoform disorders
- F48 — Other nonpsychotic mental disorders
- F50 — Eating disorders
- F51 — Sleep disorders not due to a substance or known physiological condition
- F52 — Sexual dysfunction not due to a substance or known physiological condition
- F53 — Mental and behavioral disorders associated with the puerperium, not elsewhere classified
- F54 — Psychological and behavioral factors associated with disorders or diseases classified elsewhere
- F55 — Abuse of non-psychoactive substances
- F59 — Unspecified behavioral syndromes associated with physiological disturbances and physical factors
- F60 — Specific personality disorders
- F63 — Impulse disorders
- F64 — Gender identity disorders
- F65 — Paraphilias
- F66 — Other sexual disorders
- F68 — Other disorders of adult personality and behavior
- F69 — Unspecified disorder of adult personality and behavior
- F70 — Mild intellectual disabilities
- F71 — Moderate intellectual disabilities
- F72 — Severe intellectual disabilities
- F73 — Profound intellectual disabilities
- F78 — Other intellectual disabilities
- F79 — Unspecified intellectual disabilities
- F80 — Specific developmental disorders of speech and language
- F81 — Specific developmental disorders of scholastic skills
- F82 — Specific developmental disorder of motor function
- F84 — Pervasive developmental disorders
- F88 — Other disorders of psychological development
- F89 — Unspecified disorder of psychological development
- F90 — Attention-deficit hyperactivity disorders
- F91 — Conduct disorders
- F93 — Emotional disorders with onset specific to childhood
- F94 — Disorders of social functioning with onset specific to childhood and adolescence
- F95 — Tic disorder
- F98 — Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence
- F99 — Mental disorder, not otherwise specified
Nervous System (G00–G99)68
- G00 — Bacterial meningitis, not elsewhere classified
- G01 — Meningitis in bacterial diseases classified elsewhere
- G02 — Meningitis in other infectious and parasitic diseases classified elsewhere
- G03 — Meningitis due to other and unspecified causes
- G04 — Encephalitis, myelitis and encephalomyelitis
- G05 — Encephalitis, myelitis and encephalomyelitis in diseases classified elsewhere
- G06 — Intracranial and intraspinal abscess and granuloma
- G07 — Intracranial and intraspinal abscess and granuloma in diseases classified elsewhere
- G08 — Intracranial and intraspinal phlebitis and thrombophlebitis
- G09 — Sequelae of inflammatory diseases of central nervous system
- G10 — Huntington's disease
- G11 — Hereditary ataxia
- G12 — Spinal muscular atrophy and related syndromes
- G13 — Systemic atrophies primarily affecting central nervous system in diseases classified elsewhere
- G14 — Postpolio syndrome
- G20 — Parkinson's disease
- G21 — Secondary parkinsonism
- G23 — Other degenerative diseases of basal ganglia
- G24 — Dystonia
- G25 — Other extrapyramidal and movement disorders
- G26 — Extrapyramidal and movement disorders in diseases classified elsewhere
- G30 — Alzheimer's disease
- G31 — Other degenerative diseases of nervous system, not elsewhere classified
- G32 — Other degenerative disorders of nervous system in diseases classified elsewhere
- G35 — Multiple sclerosis
- G36 — Other acute disseminated demyelination
- G37 — Other demyelinating diseases of central nervous system
- G40 — Epilepsy and recurrent seizures
- G43 — Migraine
- G44 — Other headache syndromes
- G45 — Transient cerebral ischemic attacks and related syndromes
- G46 — Vascular syndromes of brain in cerebrovascular diseases
- G47 — Sleep disorders
- G50 — Disorders of trigeminal nerve
- G51 — Facial nerve disorders
- G52 — Disorders of other cranial nerves
- G53 — Cranial nerve disorders in diseases classified elsewhere
- G54 — Nerve root and plexus disorders
- G55 — Nerve root and plexus compressions in diseases classified elsewhere
- G56 — Mononeuropathies of upper limb
- G57 — Mononeuropathies of lower limb
- G58 — Other mononeuropathies
- G59 — Mononeuropathy in diseases classified elsewhere
- G60 — Hereditary and idiopathic neuropathy
- G61 — Inflammatory polyneuropathy
- G62 — Other and unspecified polyneuropathies
- G63 — Polyneuropathy in diseases classified elsewhere
- G64 — Other disorders of peripheral nervous system
- G65 — Sequelae of inflammatory and toxic polyneuropathies
- G70 — Myasthenia gravis and other myoneural disorders
- G71 — Primary disorders of muscles
- G72 — Other and unspecified myopathies
- G73 — Disorders of myoneural junction and muscle in diseases classified elsewhere
- G80 — Cerebral palsy
- G81 — Hemiplegia and hemiparesis
- G82 — Paraplegia (paraparesis) and quadriplegia (quadriparesis)
- G83 — Other paralytic syndromes
- G89 — Pain, not elsewhere classified
- G90 — Disorders of autonomic nervous system
- G91 — Hydrocephalus
- G92 — Toxic encephalopathy
- G93 — Other disorders of brain
- G94 — Other disorders of brain in diseases classified elsewhere
- G95 — Other and unspecified diseases of spinal cord
- G96 — Other disorders of central nervous system
- G97 — Intraoperative and postprocedural complications and disorders of nervous system, not elsewhere classified
- G98 — Other disorders of nervous system not elsewhere classified
- G99 — Other disorders of nervous system in diseases classified elsewhere
Eye and Adnexa (H00–H59)40
- H00 — Hordeolum and chalazion
- H01 — Other inflammation of eyelid
- H02 — Other disorders of eyelid
- H04 — Disorders of lacrimal system
- H05 — Disorders of orbit
- H10 — Conjunctivitis
- H11 — Other disorders of conjunctiva
- H15 — Disorders of sclera
- H16 — Keratitis
- H17 — Corneal scars and opacities
- H18 — Other disorders of cornea
- H20 — Iridocyclitis
- H21 — Other disorders of iris and ciliary body
- H22 — Disorders of iris and ciliary body in diseases classified elsewhere
- H25 — Age-related cataract
- H26 — Other cataract
- H27 — Other disorders of lens
- H28 — Cataract in diseases classified elsewhere
- H30 — Chorioretinal inflammation
- H31 — Other disorders of choroid
- H32 — Chorioretinal disorders in diseases classified elsewhere
- H33 — Retinal detachments and breaks
- H34 — Retinal vascular occlusions
- H35 — Other retinal disorders
- H36 — Retinal disorders in diseases classified elsewhere
- H40 — Glaucoma
- H42 — Glaucoma in diseases classified elsewhere
- H43 — Disorders of vitreous body
- H44 — Disorders of globe
- H46 — Optic neuritis
- H47 — Other disorders of optic [2nd] nerve and visual pathways
- H49 — Paralytic strabismus
- H50 — Other strabismus
- H51 — Other disorders of binocular movement
- H52 — Disorders of refraction and accommodation
- H53 — Visual disturbances
- H54 — Blindness and low vision
- H55 — Nystagmus and other irregular eye movements
- H57 — Other disorders of eye and adnexa
- H59 — Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified
Ear and Mastoid Process (H60–H95)24
- H60 — Otitis externa
- H61 — Other disorders of external ear
- H62 — Disorders of external ear in diseases classified elsewhere
- H65 — Nonsuppurative otitis media
- H66 — Suppurative and unspecified otitis media
- H67 — Otitis media in diseases classified elsewhere
- H68 — Eustachian salpingitis and obstruction
- H69 — Other and unspecified disorders of Eustachian tube
- H70 — Mastoiditis and related conditions
- H71 — Cholesteatoma of middle ear
- H72 — Perforation of tympanic membrane
- H73 — Other disorders of tympanic membrane
- H74 — Other disorders of middle ear mastoid
- H75 — Other disorders of middle ear and mastoid in diseases classified elsewhere
- H80 — Otosclerosis
- H81 — Disorders of vestibular function
- H82 — Vertiginous syndromes in diseases classified elsewhere
- H83 — Other diseases of inner ear
- H90 — Conductive and sensorineural hearing loss
- H91 — Other and unspecified hearing loss
- H92 — Otalgia and effusion of ear
- H93 — Other disorders of ear, not elsewhere classified
- H94 — Other disorders of ear in diseases classified elsewhere
- H95 — Intraoperative and postprocedural complications and disorders of ear and mastoid process, not elsewhere classified
Circulatory System (I00–I99)80
- I00 — Rheumatic fever without heart involvement
- I01 — Rheumatic fever with heart involvement
- I1A — Other hypertension
- I02 — Rheumatic chorea
- I05 — Rheumatic mitral valve diseases
- I5A — Non-ischemic myocardial injury (non-traumatic)
- I06 — Rheumatic aortic valve diseases
- I07 — Rheumatic tricuspid valve diseases
- I08 — Multiple valve diseases
- I09 — Other rheumatic heart diseases
- I10 — Essential (primary) hypertension
- I11 — Hypertensive heart disease
- I12 — Hypertensive chronic kidney disease
- I13 — Hypertensive heart and chronic kidney disease
- I15 — Secondary hypertension
- I16 — Hypertensive crisis
- I20 — Angina pectoris
- I21 — Acute myocardial infarction
- I22 — Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction
- I23 — Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (within the 28 day period)
- I24 — Other acute ischemic heart diseases
- I25 — Chronic ischemic heart disease
- I26 — Pulmonary embolism
- I27 — Other pulmonary heart diseases
- I28 — Other diseases of pulmonary vessels
- I30 — Acute pericarditis
- I31 — Other diseases of pericardium
- I32 — Pericarditis in diseases classified elsewhere
- I33 — Acute and subacute endocarditis
- I34 — Nonrheumatic mitral valve disorders
- I35 — Nonrheumatic aortic valve disorders
- I36 — Nonrheumatic tricuspid valve disorders
- I37 — Nonrheumatic pulmonary valve disorders
- I38 — Endocarditis, valve unspecified
- I39 — Endocarditis and heart valve disorders in diseases classified elsewhere
- I40 — Acute myocarditis
- I41 — Myocarditis in diseases classified elsewhere
- I42 — Cardiomyopathy
- I43 — Cardiomyopathy in diseases classified elsewhere
- I44 — Atrioventricular and left bundle-branch block
- I45 — Other conduction disorders
- I46 — Cardiac arrest
- I47 — Paroxysmal tachycardia
- I48 — Atrial fibrillation and flutter
- I49 — Other cardiac arrhythmias
- I50 — Heart failure
- I51 — Complications and ill-defined descriptions of heart disease
- I52 — Other heart disorders in diseases classified elsewhere
- I60 — Nontraumatic subarachnoid hemorrhage
- I61 — Nontraumatic intracerebral hemorrhage
- I62 — Other and unspecified nontraumatic intracranial hemorrhage
- I63 — Cerebral infarction
- I65 — Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction
- I66 — Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction
- I67 — Other cerebrovascular diseases
- I68 — Cerebrovascular disorders in diseases classified elsewhere
- I69 — Sequelae of cerebrovascular disease
- I70 — Atherosclerosis
- I71 — Aortic aneurysm and dissection
- I72 — Other aneurysm
- I73 — Other peripheral vascular diseases
- I74 — Arterial embolism and thrombosis
- I75 — Atheroembolism
- I76 — Septic arterial embolism
- I77 — Other disorders of arteries and arterioles
- I78 — Diseases of capillaries
- I79 — Disorders of arteries, arterioles and capillaries in diseases classified elsewhere
- I80 — Phlebitis and thrombophlebitis
- I81 — Portal vein thrombosis
- I82 — Other venous embolism and thrombosis
- I83 — Varicose veins of lower extremities
- I85 — Esophageal varices
- I86 — Varicose veins of other sites
- I87 — Other disorders of veins
- I88 — Nonspecific lymphadenitis
- I89 — Other noninfective disorders of lymphatic vessels and lymph nodes
- I95 — Hypotension
- I96 — Gangrene, not elsewhere classified
- I97 — Intraoperative and postprocedural complications and disorders of circulatory system, not elsewhere classified
- I99 — Other and unspecified disorders of circulatory system
Respiratory System (J00–J99)64
- J00 — Acute nasopharyngitis [common cold]
- J01 — Acute sinusitis
- J02 — Acute pharyngitis
- J03 — Acute tonsillitis
- J04 — Acute laryngitis and tracheitis
- J4A — Chronic lung allograft dysfunction
- J05 — Acute obstructive laryngitis [croup] and epiglottitis
- J06 — Acute upper respiratory infections of multiple and unspecified sites
- J09 — Influenza due to certain identified influenza viruses
- J10 — Influenza due to other identified influenza virus
- J11 — Influenza due to unidentified influenza virus
- J12 — Viral pneumonia, not elsewhere classified
- J13 — Pneumonia due to Streptococcus pneumoniae
- J14 — Pneumonia due to Hemophilus influenzae
- J15 — Bacterial pneumonia, not elsewhere classified
- J16 — Pneumonia due to other infectious organisms, not elsewhere classified
- J17 — Pneumonia in diseases classified elsewhere
- J18 — Pneumonia, unspecified organism
- J20 — Acute bronchitis
- J21 — Acute bronchiolitis
- J22 — Unspecified acute lower respiratory infection
- J30 — Vasomotor and allergic rhinitis
- J31 — Chronic rhinitis, nasopharyngitis and pharyngitis
- J32 — Chronic sinusitis
- J33 — Nasal polyp
- J34 — Other and unspecified disorders of nose and nasal sinuses
- J35 — Chronic diseases of tonsils and adenoids
- J36 — Peritonsillar abscess
- J37 — Chronic laryngitis and laryngotracheitis
- J38 — Diseases of vocal cords and larynx, not elsewhere classified
- J39 — Other diseases of upper respiratory tract
- J40 — Bronchitis, not specified as acute or chronic
- J41 — Simple and mucopurulent chronic bronchitis
- J42 — Unspecified chronic bronchitis
- J43 — Emphysema
- J44 — Other chronic obstructive pulmonary disease
- J45 — Asthma
- J47 — Bronchiectasis
- J60 — Coalworker's pneumoconiosis
- J61 — Pneumoconiosis due to asbestos and other mineral fibers
- J62 — Pneumoconiosis due to dust containing silica
- J63 — Pneumoconiosis due to other inorganic dusts
- J64 — Unspecified pneumoconiosis
- J65 — Pneumoconiosis associated with tuberculosis
- J66 — Airway disease due to specific organic dust
- J67 — Hypersensitivity pneumonitis due to organic dust
- J68 — Respiratory conditions due to inhalation of chemicals, gases, fumes and vapors
- J69 — Pneumonitis due to solids and liquids
- J70 — Respiratory conditions due to other external agents
- J80 — Acute respiratory distress syndrome
- J81 — Pulmonary edema
- J82 — Pulmonary eosinophilia, not elsewhere classified
- J84 — Other interstitial pulmonary diseases
- J85 — Abscess of lung and mediastinum
- J86 — Pyothorax
- J90 — Pleural effusion, not elsewhere classified
- J91 — Pleural effusion in conditions classified elsewhere
- J92 — Pleural plaque
- J93 — Pneumothorax and air leak
- J94 — Other pleural conditions
- J95 — Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified
- J96 — Respiratory failure, not elsewhere classified
- J98 — Other respiratory disorders
- J99 — Respiratory disorders in diseases classified elsewhere
Digestive System (K00–K95)72
- K00 — Disorders of tooth development and eruption
- K01 — Embedded and impacted teeth
- K02 — Dental caries
- K03 — Other diseases of hard tissues of teeth
- K04 — Diseases of pulp and periapical tissues
- K05 — Gingivitis and periodontal diseases
- K06 — Other disorders of gingiva and edentulous alveolar ridge
- K08 — Other disorders of teeth and supporting structures
- K09 — Cysts of oral region, not elsewhere classified
- K11 — Diseases of salivary glands
- K12 — Stomatitis and related lesions
- K13 — Other diseases of lip and oral mucosa
- K14 — Diseases of tongue
- K20 — Esophagitis
- K21 — Gastro-esophageal reflux disease
- K22 — Other diseases of esophagus
- K23 — Disorders of esophagus in diseases classified elsewhere
- K25 — Gastric ulcer
- K26 — Duodenal ulcer
- K27 — Peptic ulcer, site unspecified
- K28 — Gastrojejunal ulcer
- K29 — Gastritis and duodenitis
- K30 — Functional dyspepsia
- K31 — Other diseases of stomach and duodenum
- K35 — Acute appendicitis
- K36 — Other appendicitis
- K37 — Unspecified appendicitis
- K38 — Other diseases of appendix
- K40 — Inguinal hernia
- K41 — Femoral hernia
- K42 — Umbilical hernia
- K43 — Ventral hernia
- K44 — Diaphragmatic hernia
- K45 — Other abdominal hernia
- K46 — Unspecified abdominal hernia
- K50 — Crohn's disease [regional enteritis]
- K51 — Ulcerative colitis
- K52 — Other and unspecified noninfective gastroenteritis and colitis
- K55 — Vascular disorders of intestine
- K56 — Paralytic ileus and intestinal obstruction without hernia
- K57 — Diverticular disease of intestine
- K58 — Irritable bowel syndrome
- K59 — Other functional intestinal disorders
- K60 — Fissure and fistula of anal and rectal regions
- K61 — Abscess of anal and rectal regions
- K62 — Other diseases of anus and rectum
- K63 — Other diseases of intestine
- K64 — Hemorrhoids and perianal venous thrombosis
- K65 — Peritonitis
- K66 — Other disorders of peritoneum
- K67 — Disorders of peritoneum in infectious diseases classified elsewhere
- K68 — Disorders of retroperitoneum
- K70 — Alcoholic liver disease
- K71 — Toxic liver disease
- K72 — Hepatic failure, not elsewhere classified
- K73 — Chronic hepatitis, not elsewhere classified
- K74 — Fibrosis and cirrhosis of liver
- K75 — Other inflammatory liver diseases
- K76 — Other diseases of liver
- K77 — Liver disorders in diseases classified elsewhere
- K80 — Cholelithiasis
- K81 — Cholecystitis
- K82 — Other diseases of gallbladder
- K83 — Other diseases of biliary tract
- K85 — Acute pancreatitis
- K86 — Other diseases of pancreas
- K87 — Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere
- K90 — Intestinal malabsorption
- K91 — Intraoperative and postprocedural complications and disorders of digestive system, not elsewhere classified
- K92 — Other diseases of digestive system
- K94 — Complications of artificial openings of the digestive system
- K95 — Complications of bariatric procedures
Skin & Subcutaneous Tissue (L00–L99)74
- L00 — Staphylococcal scalded skin syndrome
- L01 — Impetigo
- L02 — Cutaneous abscess, furuncle and carbuncle
- L03 — Cellulitis and acute lymphangitis
- L04 — Acute lymphadenitis
- L05 — Pilonidal cyst and sinus
- L08 — Other local infections of skin and subcutaneous tissue
- L10 — Pemphigus
- L11 — Other acantholytic disorders
- L12 — Pemphigoid
- L13 — Other bullous disorders
- L14 — Bullous disorders in diseases classified elsewhere
- L20 — Atopic dermatitis
- L21 — Seborrheic dermatitis
- L22 — Diaper dermatitis
- L23 — Allergic contact dermatitis
- L24 — Irritant contact dermatitis
- L25 — Unspecified contact dermatitis
- L26 — Exfoliative dermatitis
- L27 — Dermatitis due to substances taken internally
- L28 — Lichen simplex chronicus and prurigo
- L29 — Pruritus
- L30 — Other and unspecified dermatitis
- L40 — Psoriasis
- L41 — Parapsoriasis
- L42 — Pityriasis rosea
- L43 — Lichen planus
- L44 — Other papulosquamous disorders
- L45 — Papulosquamous disorders in diseases classified elsewhere
- L49 — Exfoliation due to erythematous conditions according to extent of body surface involved
- L50 — Urticaria
- L51 — Erythema multiforme
- L52 — Erythema nodosum
- L53 — Other erythematous conditions
- L54 — Erythema in diseases classified elsewhere
- L55 — Sunburn
- L56 — Other acute skin changes due to ultraviolet radiation
- L57 — Skin changes due to chronic exposure to nonionizing radiation
- L58 — Radiodermatitis
- L59 — Other disorders of skin and subcutaneous tissue related to radiation
- L60 — Nail disorders
- L62 — Nail disorders in diseases classified elsewhere
- L63 — Alopecia areata
- L64 — Androgenic alopecia
- L65 — Other nonscarring hair loss
- L66 — Cicatricial alopecia [scarring hair loss]
- L67 — Hair color and hair shaft abnormalities
- L68 — Hypertrichosis
- L70 — Acne
- L71 — Rosacea
- L72 — Follicular cysts of skin and subcutaneous tissue
- L73 — Other follicular disorders
- L74 — Eccrine sweat disorders
- L75 — Apocrine sweat disorders
- L76 — Intraoperative and postprocedural complications of skin and subcutaneous tissue
- L80 — Vitiligo
- L81 — Other disorders of pigmentation
- L82 — Seborrheic keratosis
- L83 — Acanthosis nigricans
- L84 — Corns and callosities
- L85 — Other epidermal thickening
- L86 — Keratoderma in diseases classified elsewhere
- L87 — Transepidermal elimination disorders
- L88 — Pyoderma gangrenosum
- L89 — Pressure ulcer
- L90 — Atrophic disorders of skin
- L91 — Hypertrophic disorders of skin
- L92 — Granulomatous disorders of skin and subcutaneous tissue
- L93 — Lupus erythematosus
- L94 — Other localized connective tissue disorders
- L95 — Vasculitis limited to skin, not elsewhere classified
- L97 — Non-pressure chronic ulcer of lower limb, not elsewhere classified
- L98 — Other disorders of skin and subcutaneous tissue, not elsewhere classified
- L99 — Other disorders of skin and subcutaneous tissue in diseases classified elsewhere
Musculoskeletal System (M00–M99)79
- M00 — Pyogenic arthritis
- M01 — Direct infections of joint in infectious and parasitic diseases classified elsewhere
- M1A — Chronic gout
- M02 — Postinfective and reactive arthropathies
- M04 — Autoinflammatory syndromes
- M05 — Rheumatoid arthritis with rheumatoid factor
- M06 — Other rheumatoid arthritis
- M07 — Enteropathic arthropathies
- M08 — Juvenile arthritis
- M10 — Gout
- M11 — Other crystal arthropathies
- M12 — Other and unspecified arthropathy
- M13 — Other arthritis
- M14 — Arthropathies in other diseases classified elsewhere
- M15 — Polyosteoarthritis
- M16 — Osteoarthritis of hip
- M17 — Osteoarthritis of knee
- M18 — Osteoarthritis of first carpometacarpal joint
- M19 — Other and unspecified osteoarthritis
- M20 — Acquired deformities of fingers and toes
- M21 — Other acquired deformities of limbs
- M22 — Disorder of patella
- M23 — Internal derangement of knee
- M24 — Other specific joint derangements
- M25 — Other joint disorder, not elsewhere classified
- M26 — Dentofacial anomalies [including malocclusion]
- M27 — Other diseases of jaws
- M30 — Polyarteritis nodosa and related conditions
- M31 — Other necrotizing vasculopathies
- M32 — Systemic lupus erythematosus (SLE)
- M33 — Dermatopolymyositis
- M34 — Systemic sclerosis [scleroderma]
- M35 — Other systemic involvement of connective tissue
- M36 — Systemic disorders of connective tissue in diseases classified elsewhere
- M40 — Kyphosis and lordosis
- M41 — Scoliosis
- M42 — Spinal osteochondrosis
- M43 — Other deforming dorsopathies
- M45 — Ankylosing spondylitis
- M46 — Other inflammatory spondylopathies
- M47 — Spondylosis
- M48 — Other spondylopathies
- M49 — Spondylopathies in diseases classified elsewhere
- M50 — Cervical disc disorders
- M51 — Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders
- M53 — Other and unspecified dorsopathies, not elsewhere classified
- M54 — Dorsalgia
- M60 — Myositis
- M61 — Calcification and ossification of muscle
- M62 — Other disorders of muscle
- M63 — Disorders of muscle in diseases classified elsewhere
- M65 — Synovitis and tenosynovitis
- M66 — Spontaneous rupture of synovium and tendon
- M67 — Other disorders of synovium and tendon
- M70 — Soft tissue disorders related to use, overuse and pressure
- M71 — Other bursopathies
- M72 — Fibroblastic disorders
- M75 — Shoulder lesions
- M76 — Enthesopathies, lower limb, excluding foot
- M77 — Other enthesopathies
- M79 — Other and unspecified soft tissue disorders, not elsewhere classified
- M80 — Osteoporosis with current pathological fracture
- M81 — Osteoporosis without current pathological fracture
- M83 — Adult osteomalacia
- M84 — Disorder of continuity of bone
- M85 — Other disorders of bone density and structure
- M86 — Osteomyelitis
- M87 — Osteonecrosis
- M88 — Osteitis deformans [Paget's disease of bone]
- M89 — Other disorders of bone
- M90 — Osteopathies in diseases classified elsewhere
- M91 — Juvenile osteochondrosis of hip and pelvis
- M92 — Other juvenile osteochondrosis
- M93 — Other osteochondropathies
- M94 — Other disorders of cartilage
- M95 — Other acquired deformities of musculoskeletal system and connective tissue
- M96 — Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified
- M97 — Periprosthetic fracture around internal prosthetic joint
- M99 — Biomechanical lesions, not elsewhere classified
Genitourinary System (N00–N99)85
- N00 — Acute nephritic syndrome
- N01 — Rapidly progressive nephritic syndrome
- N02 — Recurrent and persistent hematuria
- N03 — Chronic nephritic syndrome
- N04 — Nephrotic syndrome
- N05 — Unspecified nephritic syndrome
- N06 — Isolated proteinuria with specified morphological lesion
- N07 — Hereditary nephropathy, not elsewhere classified
- N08 — Glomerular disorders in diseases classified elsewhere
- N10 — Acute pyelonephritis
- N11 — Chronic tubulo-interstitial nephritis
- N12 — Tubulo-interstitial nephritis, not specified as acute or chronic
- N13 — Obstructive and reflux uropathy
- N14 — Drug- and heavy-metal-induced tubulo-interstitial and tubular conditions
- N15 — Other renal tubulo-interstitial diseases
- N16 — Renal tubulo-interstitial disorders in diseases classified elsewhere
- N17 — Acute kidney failure
- N18 — Chronic kidney disease (CKD)
- N19 — Unspecified kidney failure
- N20 — Calculus of kidney and ureter
- N21 — Calculus of lower urinary tract
- N22 — Calculus of urinary tract in diseases classified elsewhere
- N23 — Unspecified renal colic
- N25 — Disorders resulting from impaired renal tubular function
- N26 — Unspecified contracted kidney
- N27 — Small kidney of unknown cause
- N28 — Other disorders of kidney and ureter, not elsewhere classified
- N29 — Other disorders of kidney and ureter in diseases classified elsewhere
- N30 — Cystitis
- N31 — Neuromuscular dysfunction of bladder, not elsewhere classified
- N32 — Other disorders of bladder
- N33 — Bladder disorders in diseases classified elsewhere
- N34 — Urethritis and urethral syndrome
- N35 — Urethral stricture
- N36 — Other disorders of urethra
- N37 — Urethral disorders in diseases classified elsewhere
- N39 — Other disorders of urinary system
- N40 — Benign prostatic hyperplasia
- N41 — Inflammatory diseases of prostate
- N42 — Other and unspecified disorders of prostate
- N43 — Hydrocele and spermatocele
- N44 — Noninflammatory disorders of testis
- N45 — Orchitis and epididymitis
- N46 — Male infertility
- N47 — Disorders of prepuce
- N48 — Other disorders of penis
- N49 — Inflammatory disorders of male genital organs, not elsewhere classified
- N50 — Other and unspecified disorders of male genital organs
- N51 — Disorders of male genital organs in diseases classified elsewhere
- N52 — Male erectile dysfunction
- N53 — Other male sexual dysfunction
- N60 — Benign mammary dysplasia
- N61 — Inflammatory disorders of breast
- N62 — Hypertrophy of breast
- N63 — Unspecified lump in breast
- N64 — Other disorders of breast
- N65 — Deformity and disproportion of reconstructed breast
- N70 — Salpingitis and oophoritis
- N71 — Inflammatory disease of uterus, except cervix
- N72 — Inflammatory disease of cervix uteri
- N73 — Other female pelvic inflammatory diseases
- N74 — Female pelvic inflammatory disorders in diseases classified elsewhere
- N75 — Diseases of Bartholin's gland
- N76 — Other inflammation of vagina and vulva
- N77 — Vulvovaginal ulceration and inflammation in diseases classified elsewhere
- N80 — Endometriosis
- N81 — Female genital prolapse
- N82 — Fistulae involving female genital tract
- N83 — Noninflammatory disorders of ovary, fallopian tube and broad ligament
- N84 — Polyp of female genital tract
- N85 — Other noninflammatory disorders of uterus, except cervix
- N86 — Erosion and ectropion of cervix uteri
- N87 — Dysplasia of cervix uteri
- N88 — Other noninflammatory disorders of cervix uteri
- N89 — Other noninflammatory disorders of vagina
- N90 — Other noninflammatory disorders of vulva and perineum
- N91 — Absent, scanty and rare menstruation
- N92 — Excessive, frequent and irregular menstruation
- N93 — Other abnormal uterine and vaginal bleeding
- N94 — Pain and other conditions associated with female genital organs and menstrual cycle
- N95 — Menopausal and other perimenopausal disorders
- N96 — Recurrent pregnancy loss
- N97 — Female infertility
- N98 — Complications associated with artificial fertilization
- N99 — Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified
Pregnancy, Childbirth & Puerperium (O00–O9A)9
- O00 — Ectopic pregnancy
- O01 — Hydatidiform mole
- O02 — Other abnormal products of conception
- O03 — Spontaneous abortion
- O04 — Complications following (induced) termination of pregnancy
- O07 — Failed attempted termination of pregnancy
- O08 — Complications following ectopic and molar pregnancy
- O09 — Supervision of high risk pregnancy
- O9A — Maternal malignant neoplasms, traumatic injuries and abuse classifiable elsewhere but complicating pregnancy, childbirth and the puerperium
Perinatal Period Conditions (P00–P96)59
- P00 — Newborn affected by maternal conditions that may be unrelated to present pregnancy
- P01 — Newborn affected by maternal complications of pregnancy
- P02 — Newborn affected by complications of placenta, cord and membranes
- P03 — Newborn affected by other complications of labor and delivery
- P04 — Newborn affected by noxious substances transmitted via placenta or breast milk
- P05 — Disorders of newborn related to slow fetal growth and fetal malnutrition
- P07 — Disorders of newborn related to short gestation and low birth weight, not elsewhere classified
- P08 — Disorders of newborn related to long gestation and high birth weight
- P09 — Abnormal findings on neonatal screening
- P10 — Intracranial laceration and hemorrhage due to birth injury
- P11 — Other birth injuries to central nervous system
- P12 — Birth injury to scalp
- P13 — Birth injury to skeleton
- P14 — Birth injury to peripheral nervous system
- P15 — Other birth injuries
- P19 — Metabolic acidemia in newborn
- P22 — Respiratory distress of newborn
- P23 — Congenital pneumonia
- P24 — Neonatal aspiration
- P25 — Interstitial emphysema and related conditions originating in the perinatal period
- P26 — Pulmonary hemorrhage originating in the perinatal period
- P27 — Chronic respiratory disease originating in the perinatal period
- P28 — Other respiratory conditions originating in the perinatal period
- P29 — Cardiovascular disorders originating in the perinatal period
- P35 — Congenital viral diseases
- P36 — Bacterial sepsis of newborn
- P37 — Other congenital infectious and parasitic diseases
- P38 — Omphalitis of newborn
- P39 — Other infections specific to the perinatal period
- P50 — Newborn affected by intrauterine (fetal) blood loss
- P51 — Umbilical hemorrhage of newborn
- P52 — Intracranial nontraumatic hemorrhage of newborn
- P53 — Hemorrhagic disease of newborn
- P54 — Other neonatal hemorrhages
- P55 — Hemolytic disease of newborn
- P56 — Hydrops fetalis due to hemolytic disease
- P57 — Kernicterus
- P58 — Neonatal jaundice due to other excessive hemolysis
- P59 — Neonatal jaundice from other and unspecified causes
- P60 — Disseminated intravascular coagulation of newborn
- P61 — Other perinatal hematological disorders
- P70 — Transitory disorders of carbohydrate metabolism specific to newborn
- P71 — Transitory neonatal disorders of calcium and magnesium metabolism
- P72 — Other transitory neonatal endocrine disorders
- P74 — Other transitory neonatal electrolyte and metabolic disturbances
- P76 — Other intestinal obstruction of newborn
- P77 — Necrotizing enterocolitis of newborn
- P78 — Other perinatal digestive system disorders
- P80 — Hypothermia of newborn
- P81 — Other disturbances of temperature regulation of newborn
- P83 — Other conditions of integument specific to newborn
- P84 — Other problems with newborn
- P90 — Convulsions of newborn
- P91 — Other disturbances of cerebral status of newborn
- P92 — Feeding problems of newborn
- P93 — Reactions and intoxications due to drugs administered to newborn
- P94 — Disorders of muscle tone of newborn
- P95 — Stillbirth
- P96 — Other conditions originating in the perinatal period
Congenital Malformations (Q00–Q99)87
- Q00 — Anencephaly and similar malformations
- Q01 — Encephalocele
- Q02 — Microcephaly
- Q03 — Congenital hydrocephalus
- Q04 — Other congenital malformations of brain
- Q05 — Spina bifida
- Q06 — Other congenital malformations of spinal cord
- Q07 — Other congenital malformations of nervous system
- Q10 — Congenital malformations of eyelid, lacrimal apparatus and orbit
- Q11 — Anophthalmos, microphthalmos and macrophthalmos
- Q12 — Congenital lens malformations
- Q13 — Congenital malformations of anterior segment of eye
- Q14 — Congenital malformations of posterior segment of eye
- Q15 — Other congenital malformations of eye
- Q16 — Congenital malformations of ear causing impairment of hearing
- Q17 — Other congenital malformations of ear
- Q18 — Other congenital malformations of face and neck
- Q20 — Congenital malformations of cardiac chambers and connections
- Q21 — Congenital malformations of cardiac septa
- Q22 — Congenital malformations of pulmonary and tricuspid valves
- Q23 — Congenital malformations of aortic and mitral valves
- Q24 — Other congenital malformations of heart
- Q25 — Congenital malformations of great arteries
- Q26 — Congenital malformations of great veins
- Q27 — Other congenital malformations of peripheral vascular system
- Q28 — Other congenital malformations of circulatory system
- Q30 — Congenital malformations of nose
- Q31 — Congenital malformations of larynx
- Q32 — Congenital malformations of trachea and bronchus
- Q33 — Congenital malformations of lung
- Q34 — Other congenital malformations of respiratory system
- Q35 — Cleft palate
- Q36 — Cleft lip
- Q37 — Cleft palate with cleft lip
- Q38 — Other congenital malformations of tongue, mouth and pharynx
- Q39 — Congenital malformations of esophagus
- Q40 — Other congenital malformations of upper alimentary tract
- Q41 — Congenital absence, atresia and stenosis of small intestine
- Q42 — Congenital absence, atresia and stenosis of large intestine
- Q43 — Other congenital malformations of intestine
- Q44 — Congenital malformations of gallbladder, bile ducts and liver
- Q45 — Other congenital malformations of digestive system
- Q50 — Congenital malformations of ovaries, fallopian tubes and broad ligaments
- Q51 — Congenital malformations of uterus and cervix
- Q52 — Other congenital malformations of female genitalia
- Q53 — Undescended and ectopic testicle
- Q54 — Hypospadias
- Q55 — Other congenital malformations of male genital organs
- Q56 — Indeterminate sex and pseudohermaphroditism
- Q60 — Renal agenesis and other reduction defects of kidney
- Q61 — Cystic kidney disease
- Q62 — Congenital obstructive defects of renal pelvis and congenital malformations of ureter
- Q63 — Other congenital malformations of kidney
- Q64 — Other congenital malformations of urinary system
- Q65 — Congenital deformities of hip
- Q66 — Congenital deformities of feet
- Q67 — Congenital musculoskeletal deformities of head, face, spine and chest
- Q68 — Other congenital musculoskeletal deformities
- Q69 — Polydactyly
- Q70 — Syndactyly
- Q71 — Reduction defects of upper limb
- Q72 — Reduction defects of lower limb
- Q73 — Reduction defects of unspecified limb
- Q74 — Other congenital malformations of limb(s)
- Q75 — Other congenital malformations of skull and face bones
- Q76 — Congenital malformations of spine and bony thorax
- Q77 — Osteochondrodysplasia with defects of growth of tubular bones and spine
- Q78 — Other osteochondrodysplasias
- Q79 — Congenital malformations of musculoskeletal system, not elsewhere classified
- Q80 — Congenital ichthyosis
- Q81 — Epidermolysis bullosa
- Q82 — Other congenital malformations of skin
- Q83 — Congenital malformations of breast
- Q84 — Other congenital malformations of integument
- Q85 — Phakomatoses, not elsewhere classified
- Q86 — Congenital malformation syndromes due to known exogenous causes, not elsewhere classified
- Q87 — Other specified congenital malformation syndromes affecting multiple systems
- Q89 — Other congenital malformations, not elsewhere classified
- Q90 — Down syndrome
- Q91 — Trisomy 18 and Trisomy 13
- Q92 — Other trisomies and partial trisomies of the autosomes, not elsewhere classified
- Q93 — Monosomies and deletions from the autosomes, not elsewhere classified
- Q95 — Balanced rearrangements and structural markers, not elsewhere classified
- Q96 — Turner's syndrome
- Q97 — Other sex chromosome abnormalities, female phenotype, not elsewhere classified
- Q98 — Other sex chromosome abnormalities, male phenotype, not elsewhere classified
- Q99 — Other chromosome abnormalities, not elsewhere classified
Symptoms, Signs & Abnormal Findings (R00–R99)89
- R00 — Abnormalities of heart beat
- R01 — Cardiac murmurs and other cardiac sounds
- R03 — Abnormal blood-pressure reading, without diagnosis
- R04 — Hemorrhage from respiratory passages
- R05 — Cough
- R06 — Abnormalities of breathing
- R07 — Pain in throat and chest
- R09 — Other symptoms and signs involving the circulatory and respiratory system
- R10 — Abdominal and pelvic pain
- R11 — Nausea and vomiting
- R12 — Heartburn
- R13 — Aphagia and dysphagia
- R14 — Flatulence and related conditions
- R15 — Fecal incontinence
- R16 — Hepatomegaly and splenomegaly, not elsewhere classified
- R17 — Unspecified jaundice
- R18 — Ascites
- R19 — Other symptoms and signs involving the digestive system and abdomen
- R20 — Disturbances of skin sensation
- R21 — Rash and other nonspecific skin eruption
- R22 — Localized swelling, mass and lump of skin and subcutaneous tissue
- R23 — Other skin changes
- R25 — Abnormal involuntary movements
- R26 — Abnormalities of gait and mobility
- R27 — Other lack of coordination
- R29 — Other symptoms and signs involving the nervous and musculoskeletal systems
- R30 — Pain associated with micturition
- R31 — Hematuria
- R32 — Unspecified urinary incontinence
- R33 — Retention of urine
- R34 — Anuria and oliguria
- R35 — Polyuria
- R36 — Urethral discharge
- R37 — Sexual dysfunction, unspecified
- R39 — Other and unspecified symptoms and signs involving the genitourinary system
- R40 — Somnolence, stupor and coma
- R41 — Other symptoms and signs involving cognitive functions and awareness
- R42 — Dizziness and giddiness
- R43 — Disturbances of smell and taste
- R44 — Other symptoms and signs involving general sensations and perceptions
- R45 — Symptoms and signs involving emotional state
- R46 — Symptoms and signs involving appearance and behavior
- R47 — Speech disturbances, not elsewhere classified
- R48 — Dyslexia and other symbolic dysfunctions, not elsewhere classified
- R49 — Voice and resonance disorders
- R50 — Fever of other and unknown origin
- R51 — Headache
- R52 — Pain, unspecified
- R53 — Malaise and fatigue
- R54 — Age-related physical debility
- R55 — Syncope and collapse
- R56 — Convulsions, not elsewhere classified
- R57 — Shock, not elsewhere classified
- R58 — Hemorrhage, not elsewhere classified
- R59 — Enlarged lymph nodes
- R60 — Edema, not elsewhere classified
- R61 — Generalized hyperhidrosis
- R62 — Lack of expected normal physiological development in childhood and adults
- R63 — Symptoms and signs concerning food and fluid intake
- R64 — Cachexia
- R65 — Symptoms and signs specifically associated with systemic inflammation and infection
- R68 — Other general symptoms and signs
- R69 — Illness, unspecified
- R70 — Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity
- R71 — Abnormality of red blood cells
- R73 — Elevated blood glucose level
- R74 — Abnormal serum enzyme levels
- R75 — Inconclusive laboratory evidence of human immunodeficiency virus [HIV]
- R76 — Other abnormal immunological findings in serum
- R77 — Other abnormalities of plasma proteins
- R78 — Findings of drugs and other substances, not normally found in blood
- R79 — Other abnormal findings of blood chemistry
- R80 — Proteinuria
- R81 — Glycosuria
- R82 — Other and unspecified abnormal findings in urine
- R83 — Abnormal findings in cerebrospinal fluid
- R84 — Abnormal findings in specimens from respiratory organs and thorax
- R85 — Abnormal findings in specimens from digestive organs and abdominal cavity
- R86 — Abnormal findings in specimens from male genital organs
- R87 — Abnormal findings in specimens from female genital organs
- R88 — Abnormal findings in other body fluids and substances
- R89 — Abnormal findings in specimens from other organs, systems and tissues
- R90 — Abnormal findings on diagnostic imaging of central nervous system
- R91 — Abnormal findings on diagnostic imaging of lung
- R92 — Abnormal and inconclusive findings on diagnostic imaging of breast
- R93 — Abnormal findings on diagnostic imaging of other body structures
- R94 — Abnormal results of function studies
- R97 — Abnormal tumor markers
- R99 — Ill-defined and unknown cause of mortality
Injury, Poisoning & External Causes (S00–T88)171
- S00 — Superficial injury of head
- S01 — Open wound of head
- S02 — Fracture of skull and facial bones
- S03 — Dislocation and sprain of joints and ligaments of head
- S04 — Injury of cranial nerve
- S05 — Injury of eye and orbit
- S06 — Intracranial injury
- S07 — Crushing injury of head
- S08 — Avulsion and traumatic amputation of part of head
- S09 — Other and unspecified injuries of head
- S10 — Superficial injury of neck
- S11 — Open wound of neck
- S12 — Fracture of cervical vertebra and other parts of neck
- S13 — Dislocation and sprain of joints and ligaments at neck level
- S14 — Injury of nerves and spinal cord at neck level
- S15 — Injury of blood vessels at neck level
- S16 — Injury of muscle, fascia and tendon at neck level
- S17 — Crushing injury of neck
- S19 — Other specified and unspecified injuries of neck
- S20 — Superficial injury of thorax
- S21 — Open wound of thorax
- S22 — Fracture of rib(s), sternum and thoracic spine
- S23 — Dislocation and sprain of joints and ligaments of thorax
- S24 — Injury of nerves and spinal cord at thorax level
- S25 — Injury of blood vessels of thorax
- S26 — Injury of heart
- S27 — Injury of other and unspecified intrathoracic organs
- S28 — Crushing injury of thorax, and traumatic amputation of part of thorax
- S29 — Other and unspecified injuries of thorax
- S30 — Superficial injury of abdomen, lower back, pelvis and external genitals
- S31 — Open wound of abdomen, lower back, pelvis and external genitals
- S32 — Fracture of lumbar spine and pelvis
- S33 — Dislocation and sprain of joints and ligaments of lumbar spine and pelvis
- S34 — Injury of lumbar and sacral spinal cord and nerves at abdomen, lower back and pelvis level
- S35 — Injury of blood vessels at abdomen, lower back and pelvis level
- S36 — Injury of intra-abdominal organs
- S37 — Injury of urinary and pelvic organs
- S38 — Crushing injury and traumatic amputation of abdomen, lower back, pelvis and external genitals
- S39 — Other and unspecified injuries of abdomen, lower back, pelvis and external genitals
- S40 — Superficial injury of shoulder and upper arm
- S41 — Open wound of shoulder and upper arm
- S42 — Fracture of shoulder and upper arm
- S43 — Dislocation and sprain of joints and ligaments of shoulder girdle
- S44 — Injury of nerves at shoulder and upper arm level
- S45 — Injury of blood vessels at shoulder and upper arm level
- S46 — Injury of muscle, fascia and tendon at shoulder and upper arm level
- S47 — Crushing injury of shoulder and upper arm
- S48 — Traumatic amputation of shoulder and upper arm
- S49 — Other and unspecified injuries of shoulder and upper arm
- S50 — Superficial injury of elbow and forearm
- S51 — Open wound of elbow and forearm
- S52 — Fracture of forearm
- S53 — Dislocation and sprain of joints and ligaments of elbow
- S54 — Injury of nerves at forearm level
- S55 — Injury of blood vessels at forearm level
- S56 — Injury of muscle, fascia and tendon at forearm level
- S57 — Crushing injury of elbow and forearm
- S58 — Traumatic amputation of elbow and forearm
- S59 — Other and unspecified injuries of elbow and forearm
- S60 — Superficial injury of wrist, hand and fingers
- S61 — Open wound of wrist, hand and fingers
- S62 — Fracture at wrist and hand level
- S63 — Dislocation and sprain of joints and ligaments at wrist and hand level
- S64 — Injury of nerves at wrist and hand level
- S65 — Injury of blood vessels at wrist and hand level
- S66 — Injury of muscle, fascia and tendon at wrist and hand level
- S67 — Crushing injury of wrist, hand and fingers
- S68 — Traumatic amputation of wrist, hand and fingers
- S69 — Other and unspecified injuries of wrist, hand and finger(s)
- S70 — Superficial injury of hip and thigh
- S71 — Open wound of hip and thigh
- S72 — Fracture of femur
- S73 — Dislocation and sprain of joint and ligaments of hip
- S74 — Injury of nerves at hip and thigh level
- S75 — Injury of blood vessels at hip and thigh level
- S76 — Injury of muscle, fascia and tendon at hip and thigh level
- S77 — Crushing injury of hip and thigh
- S78 — Traumatic amputation of hip and thigh
- S79 — Other and unspecified injuries of hip and thigh
- S80 — Superficial injury of knee and lower leg
- S81 — Open wound of knee and lower leg
- S82 — Fracture of lower leg, including ankle
- S83 — Dislocation and sprain of joints and ligaments of knee
- S84 — Injury of nerves at lower leg level
- S85 — Injury of blood vessels at lower leg level
- S86 — Injury of muscle, fascia and tendon at lower leg level
- S87 — Crushing injury of lower leg
- S88 — Traumatic amputation of lower leg
- S89 — Other and unspecified injuries of lower leg
- S90 — Superficial injury of ankle, foot and toes
- S91 — Open wound of ankle, foot and toes
- S92 — Fracture of foot and toe, except ankle
- S93 — Dislocation and sprain of joints and ligaments at ankle, foot and toe level
- S94 — Injury of nerves at ankle and foot level
- S95 — Injury of blood vessels at ankle and foot level
- S96 — Injury of muscle and tendon at ankle and foot level
- S97 — Crushing injury of ankle and foot
- S98 — Traumatic amputation of ankle and foot
- S99 — Other and unspecified injuries of ankle and foot
- T07 — Unspecified multiple injuries
- T14 — Injury of unspecified body region
- T15 — Foreign body on external eye
- T16 — Foreign body in ear
- T17 — Foreign body in respiratory tract
- T18 — Foreign body in alimentary tract
- T19 — Foreign body in genitourinary tract
- T20 — Burn and corrosion of head, face, and neck
- T21 — Burn and corrosion of trunk
- T22 — Burn and corrosion of shoulder and upper limb, except wrist and hand
- T23 — Burn and corrosion of wrist and hand
- T24 — Burn and corrosion of lower limb, except ankle and foot
- T25 — Burn and corrosion of ankle and foot
- T26 — Burn and corrosion confined to eye and adnexa
- T27 — Burn and corrosion of respiratory tract
- T28 — Burn and corrosion of other internal organs
- T30 — Burn and corrosion, body region unspecified
- T31 — Burns classified according to extent of body surface involved
- T32 — Corrosions classified according to extent of body surface involved
- T33 — Superficial frostbite
- T34 — Frostbite with tissue necrosis
- T36 — Poisoning by, adverse effect of and underdosing of systemic antibiotics
- T37 — Poisoning by, adverse effect of and underdosing of other systemic anti-infectives and antiparasitics
- T38 — Poisoning by, adverse effect of and underdosing of hormones and their synthetic substitutes and antagonists, not elsewhere classified
- T39 — Poisoning by, adverse effect of and underdosing of nonopioid analgesics, antipyretics and antirheumatics
- T40 — Poisoning by, adverse effect of and underdosing of narcotics and psychodysleptics [hallucinogens]
- T41 — Poisoning by, adverse effect of and underdosing of anesthetics and therapeutic gases
- T42 — Poisoning by, adverse effect of and underdosing of antiepileptic, sedative-hypnotic and antiparkinsonism drugs
- T43 — Poisoning by, adverse effect of and underdosing of psychotropic drugs, not elsewhere classified
- T44 — Poisoning by, adverse effect of and underdosing of drugs primarily affecting the autonomic nervous system
- T45 — Poisoning by, adverse effect of and underdosing of primarily systemic and hematological agents, not elsewhere classified
- T46 — Poisoning by, adverse effect of and underdosing of agents primarily affecting the cardiovascular system
- T47 — Poisoning by, adverse effect of and underdosing of agents primarily affecting the gastrointestinal system
- T48 — Poisoning by, adverse effect of and underdosing of agents primarily acting on smooth and skeletal muscles and the respiratory system
- T49 — Poisoning by, adverse effect of and underdosing of topical agents primarily affecting skin and mucous membrane and by ophthalmological, otorhinolaryngological and dental drugs
- T50 — Poisoning by, adverse effect of and underdosing of diuretics and other and unspecified drugs, medicaments and biological substances
- T51 — Toxic effect of alcohol
- T52 — Toxic effect of organic solvents
- T53 — Toxic effect of halogen derivatives of aliphatic and aromatic hydrocarbons
- T54 — Toxic effect of corrosive substances
- T55 — Toxic effect of soaps and detergents
- T56 — Toxic effect of metals
- T57 — Toxic effect of other inorganic substances
- T58 — Toxic effect of carbon monoxide
- T59 — Toxic effect of other gases, fumes and vapors
- T60 — Toxic effect of pesticides
- T61 — Toxic effect of noxious substances eaten as seafood
- T62 — Toxic effect of other noxious substances eaten as food
- T63 — Toxic effect of contact with venomous animals and plants
- T64 — Toxic effect of aflatoxin and other mycotoxin food contaminants
- T65 — Toxic effect of other and unspecified substances
- T66 — Radiation sickness, unspecified
- T67 — Effects of heat and light
- T68 — Hypothermia
- T69 — Other effects of reduced temperature
- T70 — Effects of air pressure and water pressure
- T71 — Asphyxiation
- T73 — Effects of other deprivation
- T74 — Adult and child abuse, neglect and other maltreatment, confirmed
- T75 — Other and unspecified effects of other external causes
- T76 — Adult and child abuse, neglect and other maltreatment, suspected
- T78 — Adverse effects, not elsewhere classified
- T79 — Certain early complications of trauma, not elsewhere classified
- T80 — Complications following infusion, transfusion and therapeutic injection
- T81 — Complications of procedures, not elsewhere classified
- T82 — Complications of cardiac and vascular prosthetic devices, implants and grafts
- T83 — Complications of genitourinary prosthetic devices, implants and grafts
- T84 — Complications of internal orthopedic prosthetic devices, implants and grafts
- T85 — Complications of other internal prosthetic devices, implants and grafts
- T86 — Complications of transplanted organs and tissue
- T87 — Complications peculiar to reattachment and amputation
- T88 — Other complications of surgical and medical care, not elsewhere classified
External Causes of Morbidity (V00–Y99)273
- V00 — Pedestrian conveyance accident
- V01 — Pedestrian injured in collision with pedal cycle
- V02 — Pedestrian injured in collision with two- or three-wheeled motor vehicle
- V03 — Pedestrian injured in collision with car, pick-up truck or van
- V04 — Pedestrian injured in collision with heavy transport vehicle or bus
- V05 — Pedestrian injured in collision with railway train or railway vehicle
- V06 — Pedestrian injured in collision with other nonmotor vehicle
- V09 — Pedestrian injured in other and unspecified transport accidents
- V10 — Pedal cycle rider injured in collision with pedestrian or animal
- V11 — Pedal cycle rider injured in collision with other pedal cycle
- V12 — Pedal cycle rider injured in collision with two- or three-wheeled motor vehicle
- V13 — Pedal cycle rider injured in collision with car, pick-up truck or van
- V14 — Pedal cycle rider injured in collision with heavy transport vehicle or bus
- V15 — Pedal cycle rider injured in collision with railway train or railway vehicle
- V16 — Pedal cycle rider injured in collision with other nonmotor vehicle
- V17 — Pedal cycle rider injured in collision with fixed or stationary object
- V18 — Pedal cycle rider injured in noncollision transport accident
- V19 — Pedal cycle rider injured in other and unspecified transport accidents
- V20 — Motorcycle rider injured in collision with pedestrian or animal
- V21 — Motorcycle rider injured in collision with pedal cycle
- V22 — Motorcycle rider injured in collision with two- or three-wheeled motor vehicle
- V23 — Motorcycle rider injured in collision with car, pick-up truck or van
- V24 — Motorcycle rider injured in collision with heavy transport vehicle or bus
- V25 — Motorcycle rider injured in collision with railway train or railway vehicle
- V26 — Motorcycle rider injured in collision with other nonmotor vehicle
- V27 — Motorcycle rider injured in collision with fixed or stationary object
- V28 — Motorcycle rider injured in noncollision transport accident
- V29 — Motorcycle rider injured in other and unspecified transport accidents
- V30 — Occupant of three-wheeled motor vehicle injured in collision with pedestrian or animal
- V31 — Occupant of three-wheeled motor vehicle injured in collision with pedal cycle
- V32 — Occupant of three-wheeled motor vehicle injured in collision with two- or three-wheeled motor vehicle
- V33 — Occupant of three-wheeled motor vehicle injured in collision with car, pick-up truck or van
- V34 — Occupant of three-wheeled motor vehicle injured in collision with heavy transport vehicle or bus
- V35 — Occupant of three-wheeled motor vehicle injured in collision with railway train or railway vehicle
- V36 — Occupant of three-wheeled motor vehicle injured in collision with other nonmotor vehicle
- V37 — Occupant of three-wheeled motor vehicle injured in collision with fixed or stationary object
- V38 — Occupant of three-wheeled motor vehicle injured in noncollision transport accident
- V39 — Occupant of three-wheeled motor vehicle injured in other and unspecified transport accidents
- V40 — Car occupant injured in collision with pedestrian or animal
- V41 — Car occupant injured in collision with pedal cycle
- V42 — Car occupant injured in collision with two- or three-wheeled motor vehicle
- V43 — Car occupant injured in collision with car, pick-up truck or van
- V44 — Car occupant injured in collision with heavy transport vehicle or bus
- V45 — Car occupant injured in collision with railway train or railway vehicle
- V46 — Car occupant injured in collision with other nonmotor vehicle
- V47 — Car occupant injured in collision with fixed or stationary object
- V48 — Car occupant injured in noncollision transport accident
- V49 — Car occupant injured in other and unspecified transport accidents
- V50 — Occupant of pick-up truck or van injured in collision with pedestrian or animal
- V51 — Occupant of pick-up truck or van injured in collision with pedal cycle
- V52 — Occupant of pick-up truck or van injured in collision with two- or three-wheeled motor vehicle
- V53 — Occupant of pick-up truck or van injured in collision with car, pick-up truck or van
- V54 — Occupant of pick-up truck or van injured in collision with heavy transport vehicle or bus
- V55 — Occupant of pick-up truck or van injured in collision with railway train or railway vehicle
- V56 — Occupant of pick-up truck or van injured in collision with other nonmotor vehicle
- V57 — Occupant of pick-up truck or van injured in collision with fixed or stationary object
- V58 — Occupant of pick-up truck or van injured in noncollision transport accident
- V59 — Occupant of pick-up truck or van injured in other and unspecified transport accidents
- V60 — Occupant of heavy transport vehicle injured in collision with pedestrian or animal
- V61 — Occupant of heavy transport vehicle injured in collision with pedal cycle
- V62 — Occupant of heavy transport vehicle injured in collision with two- or three-wheeled motor vehicle
- V63 — Occupant of heavy transport vehicle injured in collision with car, pick-up truck or van
- V64 — Occupant of heavy transport vehicle injured in collision with heavy transport vehicle or bus
- V65 — Occupant of heavy transport vehicle injured in collision with railway train or railway vehicle
- V66 — Occupant of heavy transport vehicle injured in collision with other nonmotor vehicle
- V67 — Occupant of heavy transport vehicle injured in collision with fixed or stationary object
- V68 — Occupant of heavy transport vehicle injured in noncollision transport accident
- V69 — Occupant of heavy transport vehicle injured in other and unspecified transport accidents
- V70 — Bus occupant injured in collision with pedestrian or animal
- V71 — Bus occupant injured in collision with pedal cycle
- V72 — Bus occupant injured in collision with two- or three-wheeled motor vehicle
- V73 — Bus occupant injured in collision with car, pick-up truck or van
- V74 — Bus occupant injured in collision with heavy transport vehicle or bus
- V75 — Bus occupant injured in collision with railway train or railway vehicle
- V76 — Bus occupant injured in collision with other nonmotor vehicle
- V77 — Bus occupant injured in collision with fixed or stationary object
- V78 — Bus occupant injured in noncollision transport accident
- V79 — Bus occupant injured in other and unspecified transport accidents
- V80 — Animal-rider or occupant of animal-drawn vehicle injured in transport accident
- V81 — Occupant of railway train or railway vehicle injured in transport accident
- V82 — Occupant of powered streetcar injured in transport accident
- V83 — Occupant of special vehicle mainly used on industrial premises injured in transport accident
- V84 — Occupant of special vehicle mainly used in agriculture injured in transport accident
- V85 — Occupant of special construction vehicle injured in transport accident
- V86 — Occupant of special all-terrain or other off-road motor vehicle, injured in transport accident
- V87 — Traffic accident of specified type but victim's mode of transport unknown
- V88 — Nontraffic accident of specified type but victim's mode of transport unknown
- V89 — Motor- or nonmotor-vehicle accident, type of vehicle unspecified
- V90 — Drowning and submersion due to accident to watercraft
- V91 — Other injury due to accident to watercraft
- V92 — Drowning and submersion due to accident on board watercraft, without accident to watercraft
- V93 — Other injury due to accident on board watercraft, without accident to watercraft
- V94 — Other and unspecified water transport accidents
- V95 — Accident to powered aircraft causing injury to occupant
- V96 — Accident to nonpowered aircraft causing injury to occupant
- V97 — Other specified air transport accidents
- V98 — Other specified transport accidents
- V99 — Unspecified transport accident
- W00 — Fall due to ice and snow
- W01 — Fall on same level from slipping, tripping and stumbling
- W03 — Other fall on same level due to collision with another person
- W04 — Fall while being carried or supported by other persons
- W05 — Fall from non-moving wheelchair, nonmotorized scooter and motorized mobility scooter
- W06 — Fall from bed
- W07 — Fall from chair
- W08 — Fall from other furniture
- W09 — Fall on and from playground equipment
- W10 — Fall on and from stairs and steps
- W11 — Fall on and from ladder
- W12 — Fall on and from scaffolding
- W13 — Fall from, out of or through building or structure
- W14 — Fall from tree
- W15 — Fall from cliff
- W16 — Fall, jump or diving into water
- W17 — Other fall from one level to another
- W18 — Other slipping, tripping and stumbling and falls
- W19 — Unspecified fall
- W20 — Struck by thrown, projected or falling object
- W21 — Striking against or struck by sports equipment
- W22 — Striking against or struck by other objects
- W23 — Caught, crushed, jammed or pinched in or between objects
- W24 — Contact with lifting and transmission devices, not elsewhere classified
- W25 — Contact with sharp glass
- W26 — Contact with other sharp objects
- W27 — Contact with nonpowered hand tool
- W28 — Contact with powered lawn mower
- W29 — Contact with other powered hand tools and household machinery
- W30 — Contact with agricultural machinery
- W31 — Contact with other and unspecified machinery
- W32 — Accidental handgun discharge and malfunction
- W33 — Accidental rifle, shotgun and larger firearm discharge and malfunction
- W34 — Accidental discharge and malfunction from other and unspecified firearms and guns
- W35 — Explosion and rupture of boiler
- W36 — Explosion and rupture of gas cylinder
- W37 — Explosion and rupture of pressurized tire, pipe or hose
- W38 — Explosion and rupture of other specified pressurized devices
- W39 — Discharge of firework
- W40 — Explosion of other materials
- W42 — Exposure to noise
- W44 — Foreign body entering into or through a natural orifice
- W45 — Foreign body or object entering through skin
- W46 — Contact with hypodermic needle
- W49 — Exposure to other inanimate mechanical forces
- W50 — Accidental hit, strike, kick, twist, bite or scratch by another person
- W51 — Accidental striking against or bumped into by another person
- W52 — Crushed, pushed or stepped on by crowd or human stampede
- W53 — Contact with rodent
- W54 — Contact with dog
- W55 — Contact with other mammals
- W56 — Contact with nonvenomous marine animal
- W57 — Bitten or stung by nonvenomous insect and other nonvenomous arthropods
- W58 — Contact with crocodile or alligator
- W59 — Contact with other nonvenomous reptiles
- W60 — Contact with nonvenomous plant thorns and spines and sharp leaves
- W61 — Contact with birds (domestic) (wild)
- W62 — Contact with nonvenomous amphibians
- W64 — Exposure to other animate mechanical forces
- W65 — Accidental drowning and submersion while in bath-tub
- W67 — Accidental drowning and submersion while in swimming-pool
- W69 — Accidental drowning and submersion while in natural water
- W73 — Other specified cause of accidental non-transport drowning and submersion
- W74 — Unspecified cause of accidental drowning and submersion
- W85 — Exposure to electric transmission lines
- W86 — Exposure to other specified electric current
- W88 — Exposure to ionizing radiation
- W89 — Exposure to man-made visible and ultraviolet light
- W90 — Exposure to other nonionizing radiation
- W92 — Exposure to excessive heat of man-made origin
- W93 — Exposure to excessive cold of man-made origin
- W94 — Exposure to high and low air pressure and changes in air pressure
- W99 — Exposure to other man-made environmental factors
- X00 — Exposure to uncontrolled fire in building or structure
- X01 — Exposure to uncontrolled fire, not in building or structure
- X02 — Exposure to controlled fire in building or structure
- X03 — Exposure to controlled fire, not in building or structure
- X04 — Exposure to ignition of highly flammable material
- X05 — Exposure to ignition or melting of nightwear
- X06 — Exposure to ignition or melting of other clothing and apparel
- X08 — Exposure to other specified smoke, fire and flames
- X10 — Contact with hot drinks, food, fats and cooking oils
- X11 — Contact with hot tap-water
- X12 — Contact with other hot fluids
- X13 — Contact with steam and other hot vapors
- X14 — Contact with hot air and other hot gases
- X15 — Contact with hot household appliances
- X16 — Contact with hot heating appliances, radiators and pipes
- X17 — Contact with hot engines, machinery and tools
- X18 — Contact with other hot metals
- X19 — Contact with other heat and hot substances
- X30 — Exposure to excessive natural heat
- X31 — Exposure to excessive natural cold
- X32 — Exposure to sunlight
- X34 — Earthquake
- X35 — Volcanic eruption
- X36 — Avalanche, landslide and other earth movements
- X37 — Cataclysmic storm
- X38 — Flood
- X39 — Exposure to other forces of nature
- X50 — Overexertion and strenuous or repetitive movements
- X52 — Prolonged stay in weightless environment
- X58 — Exposure to other specified factors
- X71 — Intentional self-harm by drowning and submersion
- X72 — Intentional self-harm by handgun discharge
- X73 — Intentional self-harm by rifle, shotgun and larger firearm discharge
- X74 — Intentional self-harm by other and unspecified firearm and gun discharge
- X75 — Intentional self-harm by explosive material
- X76 — Intentional self-harm by smoke, fire and flames
- X77 — Intentional self-harm by steam, hot vapors and hot objects
- X78 — Intentional self-harm by sharp object
- X79 — Intentional self-harm by blunt object
- X80 — Intentional self-harm by jumping from a high place
- X81 — Intentional self-harm by jumping or lying in front of moving object
- X82 — Intentional self-harm by crashing of motor vehicle
- X83 — Intentional self-harm by other specified means
- X92 — Assault by drowning and submersion
- X93 — Assault by handgun discharge
- X94 — Assault by rifle, shotgun and larger firearm discharge
- X95 — Assault by other and unspecified firearm and gun discharge
- X96 — Assault by explosive material
- X97 — Assault by smoke, fire and flames
- X98 — Assault by steam, hot vapors and hot objects
- X99 — Assault by sharp object
- Y00 — Assault by blunt object
- Y01 — Assault by pushing from high place
- Y02 — Assault by pushing or placing victim in front of moving object
- Y03 — Assault by crashing of motor vehicle
- Y04 — Assault by bodily force
- Y07 — Perpetrator of assault, maltreatment and neglect
- Y08 — Assault by other specified means
- Y09 — Assault by unspecified means
- Y21 — Drowning and submersion, undetermined intent
- Y22 — Handgun discharge, undetermined intent
- Y23 — Rifle, shotgun and larger firearm discharge, undetermined intent
- Y24 — Other and unspecified firearm discharge, undetermined intent
- Y25 — Contact with explosive material, undetermined intent
- Y26 — Exposure to smoke, fire and flames, undetermined intent
- Y27 — Contact with steam, hot vapors and hot objects, undetermined intent
- Y28 — Contact with sharp object, undetermined intent
- Y29 — Contact with blunt object, undetermined intent
- Y30 — Falling, jumping or pushed from a high place, undetermined intent
- Y31 — Falling, lying or running before or into moving object, undetermined intent
- Y32 — Crashing of motor vehicle, undetermined intent
- Y33 — Other specified events, undetermined intent
- Y35 — Legal intervention
- Y36 — Operations of war
- Y37 — Military operations
- Y38 — Terrorism
- Y62 — Failure of sterile precautions during surgical and medical care
- Y63 — Failure in dosage during surgical and medical care
- Y64 — Contaminated medical or biological substances
- Y65 — Other misadventures during surgical and medical care
- Y66 — Nonadministration of surgical and medical care
- Y69 — Unspecified misadventure during surgical and medical care
- Y70 — Anesthesiology devices associated with adverse incidents
- Y71 — Cardiovascular devices associated with adverse incidents
- Y72 — Otorhinolaryngological devices associated with adverse incidents
- Y73 — Gastroenterology and urology devices associated with adverse incidents
- Y74 — General hospital and personal-use devices associated with adverse incidents
- Y75 — Neurological devices associated with adverse incidents
- Y76 — Obstetric and gynecological devices associated with adverse incidents
- Y77 — Ophthalmic devices associated with adverse incidents
- Y78 — Radiological devices associated with adverse incidents
- Y79 — Orthopedic devices associated with adverse incidents
- Y80 — Physical medicine devices associated with adverse incidents
- Y81 — General- and plastic-surgery devices associated with adverse incidents
- Y82 — Other and unspecified medical devices associated with adverse incidents
- Y83 — Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
- Y84 — Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
- Y90 — Evidence of alcohol involvement determined by blood alcohol level
- Y92 — Place of occurrence of the external cause
- Y93 — Activity codes
- Y95 — Nosocomial condition
- Y99 — External cause status
Factors Influencing Health Status (Z00–Z99)90
- Z00 — Encounter for general examination without complaint, suspected or reported diagnosis
- Z01 — Encounter for other special examination without complaint, suspected or reported diagnosis
- Z02 — Encounter for administrative examination
- Z03 — Encounter for medical observation for suspected diseases and conditions ruled out
- Z3A — Weeks of gestation
- Z04 — Encounter for examination and observation for other reasons
- Z05 — Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out
- Z08 — Encounter for follow-up examination after completed treatment for malignant neoplasm
- Z09 — Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
- Z11 — Encounter for screening for infectious and parasitic diseases
- Z12 — Encounter for screening for malignant neoplasms
- Z13 — Encounter for screening for other diseases and disorders
- Z14 — Genetic carrier
- Z15 — Genetic susceptibility to disease
- Z16 — Resistance to antimicrobial drugs
- Z17 — Estrogen, and other hormones and factors receptor status
- Z18 — Retained foreign body fragments
- Z19 — Hormone sensitivity malignancy status
- Z20 — Contact with and (suspected) exposure to communicable diseases
- Z21 — Asymptomatic human immunodeficiency virus [HIV] infection status
- Z22 — Carrier of infectious disease
- Z23 — Encounter for immunization
- Z28 — Immunization not carried out and underimmunization status
- Z29 — Encounter for other prophylactic measures
- Z30 — Encounter for contraceptive management
- Z31 — Encounter for procreative management
- Z32 — Encounter for pregnancy test and childbirth and childcare instruction
- Z33 — Pregnant state
- Z34 — Encounter for supervision of normal pregnancy
- Z36 — Encounter for antenatal screening of mother
- Z37 — Outcome of delivery
- Z38 — Liveborn infants according to place of birth and type of delivery
- Z39 — Encounter for maternal postpartum care and examination
- Z40 — Encounter for prophylactic surgery
- Z41 — Encounter for procedures for purposes other than remedying health state
- Z42 — Encounter for plastic and reconstructive surgery following medical procedure or healed injury
- Z43 — Encounter for attention to artificial openings
- Z44 — Encounter for fitting and adjustment of external prosthetic device
- Z45 — Encounter for adjustment and management of implanted device
- Z46 — Encounter for fitting and adjustment of other devices
- Z47 — Orthopedic aftercare
- Z48 — Encounter for other postprocedural aftercare
- Z49 — Encounter for care involving renal dialysis
- Z51 — Encounter for other aftercare and medical care
- Z52 — Donors of organs and tissues
- Z53 — Persons encountering health services for specific procedures and treatment, not carried out
- Z55 — Problems related to education and literacy
- Z56 — Problems related to employment and unemployment
- Z57 — Occupational exposure to risk factors
- Z58 — Problems related to physical environment
- Z59 — Problems related to housing and economic circumstances
- Z60 — Problems related to social environment
- Z62 — Problems related to upbringing
- Z63 — Other problems related to primary support group, including family circumstances
- Z64 — Problems related to certain psychosocial circumstances
- Z65 — Problems related to other psychosocial circumstances
- Z66 — Do not resuscitate
- Z67 — Blood type
- Z68 — Body mass index [BMI]
- Z69 — Encounter for mental health services for victim and perpetrator of abuse
- Z70 — Counseling related to sexual attitude, behavior and orientation
- Z71 — Persons encountering health services for other counseling and medical advice, not elsewhere classified
- Z72 — Problems related to lifestyle
- Z73 — Problems related to life management difficulty
- Z74 — Problems related to care provider dependency
- Z75 — Problems related to medical facilities and other health care
- Z76 — Persons encountering health services in other circumstances
- Z77 — Other contact with and (suspected) exposures hazardous to health
- Z78 — Other specified health status
- Z79 — Long term (current) drug therapy
- Z80 — Family history of primary malignant neoplasm
- Z81 — Family history of mental and behavioral disorders
- Z82 — Family history of certain disabilities and chronic diseases (leading to disablement)
- Z83 — Family history of other specific disorders
- Z84 — Family history of other conditions
- Z85 — Personal history of malignant neoplasm
- Z86 — Personal history of certain other diseases
- Z87 — Personal history of other diseases and conditions
- Z88 — Allergy status to drugs, medicaments and biological substances
- Z89 — Acquired absence of limb
- Z90 — Acquired absence of organs, not elsewhere classified
- Z91 — Personal risk factors, not elsewhere classified
- Z92 — Personal history of medical treatment
- Z93 — Artificial opening status
- Z94 — Transplanted organ and tissue status
- Z95 — Presence of cardiac and vascular implants and grafts
- Z96 — Presence of other functional implants
- Z97 — Presence of other devices
- Z98 — Other postprocedural states
- Z99 — Dependence on enabling machines and devices, not elsewhere classified