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PLAN OF CARE
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Medication Changes:
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Med Change Comments
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Continue Medication Rationale
• • •
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New Medication Rationale
• • •
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Taper Medication Rationale
• • •
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Type of Injection
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Injection Dictation (If not selecting values.)
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Location
• • •
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Number of Sites
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Needle
• • •
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Tolerated Well
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GIVEN BY
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ECG
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PERFORMED BY
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Urine hCG
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PERFORMED BY
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Labs
• • •
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Lab Comments
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Lithium Labs
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Labs for anticonvulsants
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Routine labs
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Blood Draw
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Nurse/MA Performing
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In office venipuncture
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Needle
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Vascular access
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Tolerated procedure well.
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Blood Dump
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Point of Care Urine Drug Screen
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MET/mAMP
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THC
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COC
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MOP
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MDMA
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BZO
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OXY
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BAR
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BUP
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MTD
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PCP
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AMP
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EDDP (Methadone Metabolites)
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TCA
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PPX
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OTHER
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NAME OF OTHER DRUG TESTED:
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Radiology
• • •
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Radiology Comments
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PT Recommendations
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PT Recommendation Comments
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Home Health
• • •
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Home health comments
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Referrals
• • •
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Referral Comments
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Referrals
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Referral Comments
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Education
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Education Comments
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Diet
• • •
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Diet comments
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General Instructions
• • •
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General Instruction Comments
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Follow-up
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Release of information
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Read
• • •
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Education
• • •
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Education Comments
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Problems Addressed
• • •
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Patient's BMI and Category
• • •
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Data Reviewed
• • •
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Time Activities
• • •
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PLAN
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REFERRALS
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LPN/RN Notified To Place Referral
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Staff Notified to Reschedule NP apt.
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Staff Notified to reschedule/schedule apt. with therapist
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Patient/CG verbalizes understanding to POC
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PMP Reviewed
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Prolonged Visit (if= >70minutes)
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Prolonged Visit 70-84 min (PPO)
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Prolonged Visit 70-84 min (medicare)
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Prolonged Visit 85-99 min (PPO)
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Prolonged Visit 85-99 min (medicare)
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Prolonged Visit >100 min (PPO)
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Low Risk (lifestyle intervention only)
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Moderate Risk (medication, minor procedure, or socially complicated)
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High Risk (major surgery or hospitalization)
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99212 (Problems=2, Data=0, Risk=low)
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99213 (Problems=3,Data =1. Risk=low)
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99214(Problems =4, Data =2, Risk=Moderate)
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99215 (Problems =5, Data = 4, Risk =High)
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99203 (Problems=3,Data =1. Risk=low)
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99204 (Problems =4, Data =2, Risk=Moderate)
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99205 (Problems =5, Data = 4, Risk =High)
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