|
MTR
|
|
|
Race
|
Language Barrier
|
|
Question Patient Has
|
Type of visit
• • •
|
|
Tobacco use
|
Recent hospital or ER visits
• • •
|
|
Smoking years
|
Type of tobacco product
|
|
Alcohol amount
|
Alcohol use
|
|
Medication Allergies & Adverse Reaction
|
|
|
PMH
• • •
|
|
|
Immunizations
|
|
|
Hep B
|
Hep A
|
|
Infuenza
|
Tdap
|
|
Pneumococcal
|
Meningococcal
|
|
Other
|
Shingles
|
|
Medication Related Problems:
|
|
|
Needs Therapy
|
|
|
Recommendations
• • •
|
Priority Level
|
|
Outcome
• • •
|
Other Recommendation
|
|
Unnecessary therapy
|
|
|
Recommendations
• • •
|
Priority level
|
|
Outcome
• • •
|
Other Recommendations
|
