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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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Point of Care Urine Drug Screen Done today?
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Point of Care Drug Screen POSITIVE for:
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Point of Care Drug Screen NEGATIVE for:
• • •
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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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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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