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PLAN
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NO MEDS PRESCRIBED TODAY
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PRESCRIBED MEDICATION(s) TODAY
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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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Lithium Labs
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Labs for anticonvulsants
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Routine labs
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Labs
• • •
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Lab Comments
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LABS/ TESTS
• • •
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Other
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Radiology
• • •
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Radiology 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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ADDITIONAL SERVICES RECOMMENDED
• • •
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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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BENZO-OPIATE RISK
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BENZODIAZEPINE RISKS DISCUSSED
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NO CARDIAC RISK FACTORS
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REFERRAL for cardiac clearance
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Other:
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STIMULANT informed consent
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DISCUSSED ABSTAINING FROM ALCOHOL AND DRUGS
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ENCOURAGED PHYSICAL EXERCISE
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SLEEP HYGIENE
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NUTRITIONAL EDUCATION
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BREASTFEEDING
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PREGNANCY while on med risk
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ANTIDEPRESSANT informed consent
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PSYCHOEDUCATION
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GUARDIAN PSYCHOEDUCATION
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Patient and GUARDIAN psychoeducation
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Patient Psychoeducation
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Other:
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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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F/U APPOINTMENT RECOMMENDED
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Other:
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NO FOLLOW UP RECOMMENDED
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Other:
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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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PMP (no inconsistencies)
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PMP (data not found)
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PMP (OTHER)
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Other:
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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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