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GENERAL CONDITION
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General condition comment
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MME
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MAPS REPORT
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Plan of care agreement
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Plan of care
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Referral
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Labs
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Other labs
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Time of labs
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What labs
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WORK NOTE
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Smoking status
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Smoking counselling
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Packs/years
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when did you quit smoking
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If BMI Over 25
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Physical
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General appearance
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Advance care planning (offered)
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Functional Ability header
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Eexhibit a steady gait
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Assisted device
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Cognitive status
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Any Falls in the interval?
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Felt down depressed/hopeless
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Expresses interest/pleasure
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Depression screening
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PHQ-9 Score
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Screening TEST/Order
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Blood Pressure code
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Systolic less than 130
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Systolic BP 130-139
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Diastolic BP <80
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Diastolic BP 80-89
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DM management
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Under nephrology care
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ACEI or ARB use
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Stain use
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Negative Microalbuminuria
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Positive Microalbuminuria
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Diabetic eye exam W/O retinopathy
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Diabetic eye exam with retinopathy
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HGA1C
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HgA1c Less than 7
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HGA1C =>7 but <8
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HGA1C =>8 but <9
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HGA1c >9
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Diabetic testing supply
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DATE
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New Glucometer
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Testing supply
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Diagnosis
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Insulin use
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Testing/day
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Reason for testing > once daily
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Quantity/3 months
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Duration and refill
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Evaluation within 6 months
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Most recent HgA1C
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Billing code
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Number and complexity of problems
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Amount and /or complexity of date to be reviewed
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FU
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