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CC:
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HPI (fillable with macro buttons or free-text)
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Meaningful Use:
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1) Depression Screening
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N/A
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In the last two weeks, have you been bothered by Little interest or pleasure in doing things?
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In the last two weeks, have you been bothered by Feeling down, depressed or hopeless?
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If "YES" to either of the above questions, click here.
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Over the past two weeks, how often have you been bothered by little interest of pleasure in doing things?
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Over the past two weeks, how often have you been bothered by feeling down, depression or hopeless?
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Over the past two weeks, how often have you been bothered by trouble falling or staying asleep or sleeping too much?
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Over the past two weeks, how often have you been bothered by feeling tired or having little energy?
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Over the past two weeks, how often have you been bothered by poor appetite or overeating?
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Over the past two weeks, how often have you been bothered by feeling bad about yourself or that you are a failure or let down?
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... trouble concentrating on things such as reading the newspaper or watching television?
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... Moving or speaking so slowly that others have noticed? Or being fidgety and restless?
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...Thoughts that you were better off dead or of hurting yourself in some way?
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Total is out of 27 points. [Depression Severity: 0-4 = none, 5-9 = mild, 10-14 = moderate, 15-19 = mod. severe, 20-27 = severe]
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Interpretation
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Depression Screening Selection
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Negative screen for clinical depression, f/u not required. (G8510)
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Positive screen for clinical depression with a documented follow-up plan (G8431)
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Screening for clinical depression not documented, pt not eligible/appropriate (G8433)
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Screening for clinical depression documented, f/u plan not documented, pt not elig/appropriate (G8940)
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2) Med list documented, reviewed
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N/A
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a. Yes
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b. No
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3) Allergies and current problems list
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N/A
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Reviewed and reconciled: Yes
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4) BMI:
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N/A
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a. In normal range, 18.5 - 25
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b. BMI > 25, follow-up plan documented
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c. BMI < 18.5, follow up plan documented
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d. BMI not documented, pt not eligible
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5) Tobacco Screening:
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N/A
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a. Tobacco non user
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b. Tobacco user
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i. Tobacco user, received brief counselling and/or pharmacotherapy
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ii. Tobacco user, did not receive smoking cessation intervention
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c. Tobacco screening not performed for medical reasons
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6) HTN screening
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N/A
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a. Normal BP, follow up not required
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b. Prehypertensive or hypertensive, follow up plan documented
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c. BP not screened, pt refused or emergenty ill
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d. Not eligible for screening as patient has active diagnosis of HTN
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i. SBP < 140 mmHg
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ii. SBP > 140 mmHg
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iii. DBP < 90 mmHg
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iv. DBP > 90 mmHg
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7) Diabetes Control checked in the past 12 months
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N/A
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a. A1C >9%
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b. A1C 7-9%
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c. A1C < 7%
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A1C not performed in the last 12 months
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8) Diabetes with eye exam in the last 12 months
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N/A
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a. Dilated retinal exam documented and reviewed
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b. Low risk for retinopathy from prior year
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9) Diabetes with foot exam in the past 12 months
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N/A
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a. Foot Exam Performed
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b. Date of exam
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c. Comments
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