Coding Documentation Template v3.4

Coding Documentation Template (V3.8 Prototype)

Complete this form after writing your clinical notes. Include all diagnoses and procedures with actions.
Steps: 1) Fill the fields. 2) Click Generate Summary. 3) Copy and paste into EMR.

Principal Diagnosis

Secondary Diagnoses and Linked Causes or Actions Taken

+ Add Secondary Diagnosis

Significant Procedures & Reasons

+ Add Procedure
Generate Summary

Summary Output: