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PCP/Specialists
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Preferred Pharmacy
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MIPS Quality Measures
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PHQ-2 Depression Screening for Patients 12 Years and Older: Over the last 2 weeks
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PHQ-2 Depression Screening Completed?
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Little Interest or Pleasure in Doing Things?
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Feeling Down, Depressed or Hopeless?
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Total PHQ-2 Score
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Screening Answer
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Depression Interventions
• • •
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Depression Comments
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Vital Measures for MIPS: Blood Pressure & BMI
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**BMI (Document EVERY Visit)
• • •
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BMI Interventions
• • •
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**Controlling High Blood Pressure (Only for pts with a dx of HTN) (Document EVERY Visit)
• • •
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HTN Interventions
• • •
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BMI & HTN Comments
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Diabetic Mellitus Measures
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Diabetic Neurological Evaluation
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Diabetic Neurological Evaluation
• • •
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Medical Reason Neuro Exam Not Completed
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5.07 Monofilament Test Displayed
• • •
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Soft Touch Sensation - Left Foot
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Soft Touch Sensation - Right Foot
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Sharpdull Sensation - Left Foot
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Sharpdull Sensation - Right Foot
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DM Neuro Interventions
• • •
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DM Neuro Exam Comments
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Diabetic Footwear Assessment & Education
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Does the patient wear appropriate shoes?
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Does the patient need inserts/orthotics?
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Did the patient have prior foot care education?
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Can the patient demonstrate appropriate self-care?
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Diabetic Foot Education Performed.
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Pt Advised to have Diabetic Foot Exam Annually.
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Evaluation of Footwear
• • •
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Diabetic Footwear Comments
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Measures for Patients 65 Years and Older
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Advance Care Plan Screening
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Does the patient have an Advance Care Plan?
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Advance Care Plan Comments:
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Advance Care Plan Documentation:
• • •
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Or does the patient have a Surrogate Decision Maker?
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Name of patient's Surrogate Decision Maker (if applicable):
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Advance Directives Screening Results
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Advance Directives Comments:
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Elder Maltreatment Screening: Within the last 12 months
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Elder Maltreatment Screening Complete
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Elder Abuse Suspicion Index
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1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
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2. Has anyone prevented you from getting medical or personal items, or from being with people you wanted to be with?
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3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
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4. Has anyone tried to force you to sign papers or to use your money against your will?
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5. Has anyone made you afraid, touched you inappropriately, or hurt you physically?
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6. Question for Provider
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Screening Results
• • •
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Elder Abuse Exam Comments
|
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Optional Documentation Below
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Falls Risk Screening: Within the last 12 months
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Has this patient had any falls in the last year?
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Falls Comments
|
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Does the patient have worries about falling or feel unsteady when standing or walking?
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Falls Comments
|
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Does the patient have any medical conditions making them a risk for falling?
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Medical Conditions Increasing Risk for Falling
• • •
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Does the patient use any assistive devices?
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Assistive Devices Patient Utilizes?
• • •
|
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Is the patient a falls risk at this time?
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Falls Risk Interventions?
• • •
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Falls Comments
|
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Immunization Screening
|
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Has the Patient Received the Current Seasonal Influenza Vaccine?
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Date Influenza Immunization Received (Month & Year)
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Has the Patient Received the Pneumonia Vaccine?
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Date Pneumonia Immunization Received (Year & Month)
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