RVUDoc2026

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Epic SmartPhrase library

146 drop-in templates for outpatient and hospital practice. Each phrase prompts you to document the work actually performed. Templates do not guarantee a billable service.

Free dot phrases: start with the encounter

Open a free preview, copy the starting text, and remove anything that does not apply. Complete every relevant placeholder. Never carry forward findings, counseling, time, or services that were not performed. Your organization's Epic configuration may require a different import workflow. RVUDoc is independent and is not affiliated with Epic Systems.

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18 free phrases

Templates are starting points. Clinical review is pending. Verify medications, thresholds and local protocols; replace placeholders and remove findings or services you did not perform. Related codes are references, not approved billing combinations.

E/M
HISTORY: *** EXAM: *** ASSESSMENT & PLAN (per problem): 1. *** (chronic, stable / chronic, mild exacerbation / acute uncomplicated) - Plan: *** - Rx: *** 2. *** - Plan: *** DATA REVIEWED: - Outside records / labs / imaging: *** - Independent interpretation: *** - Discussion with another provider: *** RISK: - Prescription drug management: *** - Decision regarding minor surgery: *** - Social determinants impacting care: *** MDM LEVEL: Moderate (supports 99214). Total visit time: *** minutes (alternative time-based code if 30-39 min total).
Notes: 2021 MDM rules: 99214 = Moderate complexity. Need 2 of 3 (number/complexity of problems addressed; amount/complexity of data reviewed; risk of complications/morbidity). OR bill by total time (30-39 min). Document one path clearly.
Allergy
AWV
Cardiology
Counseling
Critical Care
Endocrinology
General IM
Geriatrics
GI
Hematology
Hospital
Infectious Disease
Nephrology
Oncology
Pulmonology
Rheumatology
Sleep

128 more phrases in the full library

Every new account gets 14 days of full access, no card needed. The free phrases stay free after that.

Allergy · 5
  • .urticariaChronic spontaneous urticaria.
  • .cvidCommon variable immunodeficiency / Ig replacement.
  • .drugallergyDrug allergy delabeling / workup.
  • .eoeEosinophilic esophagitis.
  • .anaphylaxisPost-anaphylaxis follow-up.
AWV · 1
  • .bigAWVinitialInitial Annual Wellness Visit (G0438)
Cardiology · 11
  • .valveasAortic stenosis follow-up.
  • .afibcardsAtrial fibrillation — comprehensive cardiology follow-up.
  • .anginaChronic stable angina.
  • .dvtpeDVT/PE on outpatient anticoagulation.
  • .hfpefHFpEF management.
  • .ciedPacemaker / ICD follow-up.
  • .padPeripheral artery disease.
  • .acsPost-ACS / post-MI follow-up.
  • .preopcardsPre-operative cardiac risk evaluation.
  • .pulmhtnPulmonary hypertension surveillance.
  • .syncopeSyncope evaluation.
CCM · 1
  • .bigCCMChronic Care Management Enrollment (99490)
Counseling · 3
  • .bigDepScreenAnnual Depression Screen (G0444)
  • .bigASCVDASCVD Risk Assessment (G0537)
  • .bigSmokingSmoking Cessation Counseling (99406 / 99407)
Critical Care · 7
  • .gibleedAcute upper / lower GI bleed inpatient.
  • .ardsARDS — Berlin definition + management.
  • .dkaDKA / HHS inpatient / step-down.
  • .icudailyICU daily progress note (FAST HUG + problems).
  • .familymeetingICU family meeting / goals of care.
  • .ventMechanical ventilation settings note.
  • .sepsisbundleSepsis / septic shock — early management bundle.
E/M · 1
  • .bigG2211G2211 Justification (Complex E/M Add-on)
Endocrinology · 11
  • .adrenalinsufAdrenal insufficiency follow-up.
  • .cushingwkCushing syndrome screening / workup.
  • .gravesHyperthyroidism — Graves' disease.
  • .hyponaHyponatremia outpatient evaluation.
  • .hypogonadismMale hypogonadism evaluation / testosterone therapy.
  • .pcosPCOS management.
  • .hyperparathyroidPrimary hyperparathyroidism.
  • .prolactinomaProlactinoma surveillance.
  • .dm2endoT2DM with insulin titration / advanced therapy.
  • .thyroidnoduleThyroid nodule workup / surveillance.
  • .vitddefVitamin D deficiency.
General IM · 8
  • .alcoholbriefAlcohol use brief intervention (SBIRT).
  • .tobaccoquitBrief tobacco cessation counseling block.
  • .opioidsmmChronic opioid management visit.
  • .oudbupOUD — buprenorphine maintenance.
  • .portalmsgPortal message / asynchronous E/M response.
  • .immigrantadultRefugee / immigrant adult health screen.
  • .healthlitTeach-back & health literacy documentation.
  • .tcmTransitional care management visit (post-discharge).
Geriatrics · 7
  • .dementiaAlzheimer disease / dementia management.
  • .fallsFalls workup and prevention.
  • .acpformalFormal advance care planning visit.
  • .frailtyFrailty assessment.
  • .polypharmPolypharmacy / deprescribing review.
  • .pressureinjuryPressure injury staging and care.
  • .incontinenceUrinary incontinence — adult.
GI · 11
  • .barrettBarrett's esophagus surveillance.
  • .cdiffC. difficile infection — initial / recurrent.
  • .celiacCeliac disease.
  • .pancreatitischronicChronic pancreatitis.
  • .cirrhosisCirrhosis surveillance and complications.
  • .colonscreenColon cancer screening discussion.
  • .hpyloriH. pylori test-and-treat.
  • .hbvHepatitis B chronic management.
  • .hcvHepatitis C — treatment and follow-up.
  • .masldMASLD / MASH (formerly NAFLD/NASH).
  • .ucUlcerative colitis follow-up.
Hematology · 8
  • .b12defB12 / folate deficiency.
  • .cllsurvCLL surveillance.
  • .vteextendExtended-duration anticoagulation decision.
  • .mgusMGUS surveillance.
  • .lymphomasurvPost-lymphoma surveillance.
  • .sicklecellSickle cell disease — adult outpatient.
  • .thrombocytopeniaThrombocytopenia outpatient evaluation.
  • .thromphiliaThrombophilia evaluation discussion.
Hospital · 8
  • .amaeducationAgainst medical advice (AMA) discharge.
  • .chestpainruleoutChest pain rule-out / observation.
  • .codediscussionCode status / advance directive in hospital.
  • .soapDaily inpatient progress note.
  • .dcsummDischarge summary.
  • .vteprophInpatient VTE prophylaxis.
  • .transferacceptInter-hospital / inter-service transfer accept note.
  • .preopclearPre-operative medical clearance.
Infectious Disease · 8
  • .capCommunity-acquired pneumonia outpatient.
  • .hivmaintHIV outpatient maintenance.
  • .prepHIV PrEP — initiation / refill.
  • .lymeLyme disease — early localized to disseminated.
  • .covidlongPost-acute COVID / Long COVID.
  • .endocarditisPost-IE outpatient management.
  • .syphilisSyphilis staging and treatment.
  • .utiUncomplicated and complicated UTI.
Nephrology · 7
  • .akiAKI workup and outpatient follow-up.
  • .esrdESRD on hemodialysis or peritoneal dialysis.
  • .gnnephroticGlomerulonephritis / nephrotic syndrome workup.
  • .hypernaHypernatremia evaluation.
  • .transplantkidneyKidney transplant outpatient surveillance.
  • .nephlithNephrolithiasis — recurrent stone prevention.
  • .hyperKOutpatient hyperkalemia.
Oncology · 9
  • .cancerscreensummAge-based cancer screening summary.
  • .cancerpainCancer-related pain management.
  • .chemontChemo-induced nausea / vomiting prevention.
  • .colonsurvColorectal cancer survivorship.
  • .goalcareGoals-of-care / advance care planning visit.
  • .hospicereferralHospice referral.
  • .lungcasurvLung cancer survivorship after curative therapy.
  • .febrileneutOutpatient febrile neutropenia triage.
  • .prostatecasurvProstate cancer follow-up post-treatment / active surveillance.
Pulmonology · 9
  • .pevisitAcute / sub-acute PE outpatient management.
  • .ipfInterstitial lung disease — IPF surveillance.
  • .ltbiLatent TB infection — treatment.
  • .bronchiectasisNon-CF bronchiectasis.
  • .osaOSA — CPAP follow-up.
  • .sarcoidSarcoidosis surveillance.
  • .copdsevereSevere / advanced COPD.
  • .pulmnoduleSolitary pulmonary nodule follow-up.
  • .smokingcessTobacco cessation counseling and pharmacotherapy.
Rheumatology · 7
  • .vasculitisANCA-associated vasculitis follow-up.
  • .fibromyalgiaFibromyalgia / chronic widespread pain.
  • .goutGout — acute and chronic management.
  • .oaOsteoarthritis — knee/hip management.
  • .pmrgcaPMR / GCA evaluation and treatment.
  • .sjogrenSjögren syndrome.
  • .sleSLE — outpatient maintenance.
Sleep · 5
  • .circadianCircadian rhythm disorders / shift work.
  • .narcolepsyNarcolepsy management.
  • .osafuOSA — outpatient follow-up (post-titration).
  • .rbdREM sleep behavior disorder.
  • .rlsRestless legs syndrome.
TCM · 1
  • .bigTCMTCM Documentation (99495 / 99496)
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