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Primary Provider
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Chronic Care Manager
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Preferred method of communication
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Best time to reach me
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CPC+ Patient?
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ACO Patient?
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Reviewed medication list
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Reviewed Allergies?
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Name(s) of Specialist(s)
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Do you follow a special diet plan?
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special diet plan includes:
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Chronic conditions
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Other Chronic Conditions, please list
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Preventive Care
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Mammogram
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Date of last mammogram
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Mammogram ordered?
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Pap smear
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Date of Last pap smear
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Colonoscopy
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Date of Last Colorectal Screening
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Influenza Vaccination Complete?
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Date of Influenza Vaccination
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Osteoporosis Screening?
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Date of Last Osteoporosis Screening
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Pneumococcal Vaccination Complete?
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Date of Pneumococcal Vaccination
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Psycho-Social Needs
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Is the patient’s home safe?
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Home safety comments:
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Vision difficulties
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Does pt wear glasses?
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Any hearing difficulties?
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Does pt use hearing aid?
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Can pt handle own medications?
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If no, who administers meds?
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Does pt have a steady gait?
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Has pt fallen or had a fall injury in last 12 months?
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Does pt use assistive devices to ambulate?
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Comments:
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Recommendations include:
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MMSE Risk Score
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Did you discuss advanced care planning?
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Does pt have Advance Directive?
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Does patient have a DNR?
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Comments:
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Action Plan
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My health goal, the main thing i want to change about my health is
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Personal Goal #1
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Personal Goal #2
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Personal Goal #3
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Action steps
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Potential problems:
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Support/Resources
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Confidence in meeting my goals:
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Resources from my care manager include:
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Educational materials
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Local education classes
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Community Resources:
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Date of next Care Management Visit
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Date of next PCP appt
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