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Activities of Daily
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Do not wish to complete:
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Dress yourself
• • •
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Stand up from chair
• • •
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Shampoo hair
• • •
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Get in/our of bed
• • •
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Take bath
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Get on/off toilet
• • •
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Reach and bring down 5lb object above head
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Bend down and pick up object
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Bend down and pick up object
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Cut your meat
• • •
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Open car doors
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Lift full cup/glass to mouth
• • •
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Open previously opened jars
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Open a new milk carton
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Turn faucet on and off
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Walk outdoors (flat ground)
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Run errands and shop
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Climb up 5 steps
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Get in/out of car
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Wash/dry body
• • •
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Do chores (vacuum/yard work)
• • •
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Select any of the following that you use:
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Cane
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Walker:
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Crutches:
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Wheelchair:
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Built up chair:
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Modified/specialty utensils:
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Devices used to dress:
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Raised toilet seats:
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Bathtub bar or seat:
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Long-handled appliances for reach:
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Pain Scale Screening
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First site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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Second site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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Third site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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Fourth site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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No Pain Present
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Pain Present
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Plan of care
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Plan of care
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Fall Risk Screening
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Have you fallen within the last 12 months?
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How many times?
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Have you suffered a fracture or broken a bone due to a fall?
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Time _ seconds to walk a distance of 3 meters from sitting to standing position
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Immunizations:
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Pneumococcal Vaccine
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Date
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Where
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Prevnar Vaccine
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Date
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Where
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Flu Vaccine
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Date
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Where
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Preventative Screening:
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Mammogram
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Date
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Where
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Colorectal Screening:
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Does patient have a past history of total colectomy or colorectal cancer?
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Colonoscopy:
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Date
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Where
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Results
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Verify pathology report
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Cologuard:
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Date
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Results
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Stool FOBT:
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Date
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Results
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FOBT coding
• • •
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Flexible sigmoidoscopy:
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Date
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Results
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Health Risk Assessment:
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How would you rate your overall health?
• • •
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Do you have any problems with urinary leakage?
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Do you suffer from any short term memory problems?
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Do you suffer from any long term memory problems?
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Vital Signs
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Hypertension Screening
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Blood Pressure:
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Blood Pressure coding:
• • •
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Did the patient have a diagnosis of HTN?
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Follow up Plan:
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BMI
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BMI:
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BMI Coding:
• • •
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Was BMI abnormal?
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Follow up Plan:
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Exercise Screening:
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Do you exercise regularly?
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Duration
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Frequency:
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Face to face counseling for obesity, 15 minutes
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Advanced Care Planning:
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Date Reviewed
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Patient has:
• • •
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Advanced Care Planning coding:
• • •
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Discussed with patient or caregiver?
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Copy of plan in patient's chart?
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Cognitive Function Assessment:
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Assessed the beneficiary's cognitive function by direct observation, with due consideration of information.
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Depression in Remission at 12 months:
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Did the patient have an active diagnosis of major depression including remission or dysthymia between 12/01/2019 - 11/30/2020?
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Did the patient have one or more PHQ-9's administered between 12/01/2019 - 11/30/2020?
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Did the patient have a PHQ-9 score > 9 during an outpatient encounter between 12/01/2019 - 11/30/2020?
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Date:
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Score:
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Did the patient have one or more PHQ-9s administered 12 months (+/-30 days) after the measurement period?
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Date
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Score:
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Diabetes Mellitus*
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Does the patient have a history or active diagnosis of Diabetes in 2020 or 2021?
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Last HbA1C:
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Date
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ICD-10 Diagnosis Code:
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A1c coding
• • •
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Does the patient have a blood pressure reading below 140/90?
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Is the patient a user of tobacco?
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Aspirin use:
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Was the patient screened for diabetic retinal disease in 2020 or was a negative retinal exam captured in 2018? Must have been co
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Retinopathy
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Macular Degeneration
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Cataracts
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Glaucoma Screening:
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Date
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Where
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Abnormalities
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Most recent LDL value:
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Date
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Heart Failure (HF)
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Does the patient have a diagnosis of Heart Failure any time prior to 12/31/2021?
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If yes, does the patient have LVSD? (LVEF<40% or moderate or severe)
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If yes, was the patient prescribed a Beta Blocker in 2021?
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HF coding
• • •
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Cardiovascular Disease
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Does the patient have a diagnosis of Atherosclerotic Cardiovascular Disease (active or history of) at any time up to 12/31/2021?
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Has the patient had a fasting or direct LDL > 189mg/Dl?
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Date
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Results
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LDL coding
• • •
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Is the patient between 40-75 years old AND a Type 1 or 2 diabetic AND have a fasting or direct LDL-C between 70-189 mg/dL betwe
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If yes, is the patient currently a statin user or received a prescription in 2018?
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Statin coding
• • •
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Ischemic Vascular Disease (IVD)
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Was the patient discharged for an acute myocardial infarction, coronary artery bypass graft or percutaneous coronary
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Did patient have an active diagnosis of ischemic vascular disease in 2021?
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If yes, was the patient prescribed aspirin or another antithrombotic during the measurement period?
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IVD coding
• • •
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Was a complete lipid panel completed in 2021?
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Is the patient's LDL controlled? (<100mg/dL)
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Coronary Artery Disease (CAD)
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Does the patient have an active diagnosis of CAD or history of surgery at any time up - 12/31/21
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Diagnosis Code:
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If CAD does the patient have Diabetes?
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Diagnosis Code:
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if CAD, does the patient have LVSD? (LVEF<40% or moderate or severe)
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Diagnosis Code:
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If the patient has Diabetes or LVSD, has the patient been prescribed an ACE inhibitor or ARB therapy?
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CAD coding
• • •
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