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Patient Dx ( Discharge Dx)
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D/C Physician :
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Discharge Date :
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PCP Name
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Clinical Review Date:
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Medication list available?
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Date & time of Interactive Contact
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Patient understands goal/ therapy outcomes ?
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Method of Interactive Contact
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Patient Records reviewed ( Select all that apply)
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Is patient adherent to his medication?
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Patient is aware of their diagnosis and how to manage their condition ?
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Smoker
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COPD Group (if applicable)
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Would patient benefit from Med-Rec?
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Patient Concerns
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Notes
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Patient education for self management
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Patient vaccination history
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Referrals needed for followup :
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Provider Face-To-Face Visit :
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MDM Risk Level Result
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Appointment coordinated with:
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Followup Appointment Scheduled :
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Clinical Review completed by:
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