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Encounter ID
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Your Name
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Current attempt to reach patient
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Ticket # (if attempted by phone)
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Did chatter respond to follow up?
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Patient Progress
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What is the status of the patient's condition?
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Did the patient seek care at any of the following sites of care? (select all that apply)
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Any new symptoms?
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Medication Adherence
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Were you prescribed any new medications?
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If Yes: Did you run into any barriers to taking your (new) medications as prescribed?
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Directed to Resources for medication adherence
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Preventative Care
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Seen PCP in the last year
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If No- Reason why
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Directed to Resources for preventative care
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Additional health concerns:
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Education Discussed
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Current Symptoms
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Disease Management
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Health Promotion
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OTC Treatment
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OTC Medications
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Prescription Medications
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Level of Understanding
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Additional Notes
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Notes
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