|
Code Status
|
Allergies
|
|
|
Meds reviewed
|
|
Other Medical Providers
|
|
|
Other Medical Provider 1
|
Provider 1 Name
|
|
Other Medical Provider 2
|
Provider 2 Name
|
|
Other Medical Provider 3
|
Provider 3 Name
|
|
Other Medical Provider 4
|
Provider 4 Name
|
|
Other Medical Provider 5
|
Provider 5 Name
|
|
Other Medical Provider 6
|
Other Med Provider 6 comment
|
|
|
|
|
Chronic Medical Conditions
|
|
|
Problem 1
|
Free Text Prob 1
|
|
|
Problem 1 Plan
• • •
|
|
|
Comments 1
|
|
|
Participants in Care 1
• • •
|
|
|
Prognosis 1
|
|
Problem 2
|
Free Text Prob 2
|
|
|
Problem 2 Plan
• • •
|
|
|
Comments 2
|
|
|
Prognosis 2
|
|
|
Participants in Care 2
• • •
|
|
Problem 3
|
Free Text Prob 3
|
|
|
Problem 3 Plan
• • •
|
|
|
Comments 3
|
|
|
Prognosis 3
|
|
|
Participants in Care 3
• • •
|
|
Problem 4
|
Free Text Prob 4
|
|
|
Problem 4 Plan
• • •
|
|
|
Comments 4
|
|
|
Prognosis 4
|
|
|
Participants in Care 4
• • •
|
|
Problem 5
|
Free Text Prob 5
|
|
|
Problem 5 Plan
• • •
|
|
|
Comments 5
|
|
|
Prognosis 5
|
|
|
Participants in Care 5
• • •
|
|
Problem 6
|
Free Text Prob 6
|
|
|
Problem 6 Plan
• • •
|
|
|
Comments 6
|
|
|
Prognosis 6
|
|
|
Participants in Care 6
• • •
|
|
Problem 7
|
Free Text Prob 7
|
|
|
Problem 7 Plan
• • •
|
|
|
Comments 7
|
|
|
Prognosis 7
|
|
|
Participants in Care 7
• • •
|
|
Problem 8
|
Free Text Prob 8
|
|
|
Problem 8 Plan
• • •
|
|
|
Comments 8
|
|
|
Prognosis 8
|
|
|
Participants in Care 8
• • •
|
|
Problem 9
|
Free Text Prob 9
|
|
|
Problem 9 Plan
• • •
|
|
|
Comments 9
|
|
|
Prognosis 9
|
|
|
Participants in Care 9
• • •
|
|
Problem 10
|
Free Text Prob 10
|
|
|
Problem 10 Plan
• • •
|
|
|
Comments 10
|
|
|
Prognosis 10
|
|
|
Participants in Care 10
• • •
|
|
Free Text Prob 11
|
Other Chronic Prob 11 Comments
|
|
Free Text Prob 12
|
Other Chronic Prob 12 Comments
|
|
|
|
|
Functional Limitations
|
|
|
Mobility
• • •
|
Mobility Plan
• • •
|
|
Other Functional Limitations
• • •
|
Other Functional Limitations Plan
• • •
|
|
Cognitive Limitations
• • •
|
Cognitive Limitations Plan
• • •
|
|
Psych. Evaluation
• • •
|
Pych. Evaluation Plan
• • •
|
|
Nutritional Status
• • •
|
|
|
Diet
• • •
|
Nutrition/Diet Plan
• • •
|
|
Safety Issues in Home
• • •
|
Safety Plan
• • •
|
|
|
|
|
Immunizations
|
|
|
Flu
|
Date
|
|
Pneumovax
|
Date
|
|
Other
|
Date
|
|
Other
|
Date
|
|
|
|
|
Resources
|
|
|
Community Services Current
• • •
|
Community Services Recommended
• • •
|
|
Medical Specialty Resources Current
• • •
|
Medical Specialty Resources Recommended
• • •
|
|
Care Circle Resources
|
|
|
Geriatric Care Manager
|
GCM comment
|
|
Home Care / Private Duty
|
Home Care / Private Duty Comments
|
|
Home Health
|
HH Comment
|
|
Hospice
|
Hospice Comment
|
|
|
|
|
Preventive Services
|
|
|
Mammogram Service Plan
• • •
|
|
|
Pap and Pelvic Exam Plan
• • •
|
|
|
Prostate Cancer Screening Plan
• • •
|
|
|
Colorectal Cancer Screening Plan
• • •
|
|
|
Diabetes Self- Management Plan
• • •
|
|
|
Bone Mass Measurements Plan
• • •
|
|
|
Glaucoma Screening Plan
• • •
|
|
|
Medical Nutrition Therapy Plan
• • •
|
|
|
Cardiovascular Screening Plan
• • •
|
|
|
Diabetes Screening Plan
• • •
|
|
|
Abdominal Aortic Aneurysm Screening Plan
• • •
|
|
|
HIV Screening Plan
• • •
|
|
|
Smoking Cessation Counseling Plan
• • •
|
|
|
Subsequent AWV Plan
• • •
|
|
|
Screening Comments
|
|
|
Overall POC comments
|
|
