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Activities of Daily
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Do not wish to complete:
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Dress yourself
• • •
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Stand up from chair
• • •
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Shampoo hair
• • •
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Get in/our of bed
• • •
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Take bath
• • •
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Get on/off toilet
• • •
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Reach and bring down 5lb object above head
• • •
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Bend down and pick up object
• • •
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Bend down and pick up object
• • •
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Cut your meat
• • •
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Open car doors
• • •
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Lift full cup/glass to mouth
• • •
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Open previously opened jars
• • •
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Open a new milk carton
• • •
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Turn faucet on and off
• • •
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Walk outdoors (flat ground)
• • •
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Run errands and shop
• • •
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Climb up 5 steps
• • •
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Get in/out of car
• • •
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Wash/dry body
• • •
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Do chores (vacuum/yard work)
• • •
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Select any of the following that you use:
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Cane
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Walker:
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Crutches:
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Wheelchair:
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Built up chair:
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Modified/specialty utensils:
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Devices used to dress:
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Raised toilet seats:
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Bathtub bar or seat:
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Long-handled appliances for reach:
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Pain Scale Screening
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First site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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Second site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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Third site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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Fourth site of pain
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Constant/Intermittent
• • •
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Without Medication
• • •
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With Medication
• • •
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No Pain Present
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Pain Present
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Plan of care
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Plan of care
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Fall Risk Screening
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Have you fallen within the last 12 months?
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How many times?
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Screen more than 2 falls
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FRA w/documentation
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FRA not completed for medical reasons
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Have you suffered a fracture or broken a bone due to a fall?
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Time _ seconds to walk a distance of 3 meters from sitting to standing position
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Immunizations:
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Pneumococcal Vaccine
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Date
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Where
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Prevnar Vaccine
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Date
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Where
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PCV20 Vaccine
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Date
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Where
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Flu Vaccine
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Date
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Where
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Shingles Vaccine
|
Date
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COVID-19 Vaccine
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Date
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Where
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Manufacturer
• • •
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Preventative Screening:
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Mammogram
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Date
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Where
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Colorectal Screening:
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Does patient have a past history of total colectomy or colorectal cancer?
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Colonoscopy:
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Date
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Where
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Results
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Verify pathology report
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Cologuard:
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Date
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Results
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Stool FOBT:
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Date
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Results
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FOBT coding
• • •
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DO NOT FORGET TO CODE
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Flexible sigmoidoscopy:
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Date
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Results
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Health Risk Assessment:
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How would you rate your overall health?
• • •
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Do you have any problems with urinary leakage?
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Do you suffer from any short term memory problems?
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Do you suffer from any long term memory problems?
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Hypertension Screening
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Blood Pressure:
|
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Blood Pressure coding:
• • •
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DO NOT FORGET TO CODE
|
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Did the patient have a diagnosis of HTN?
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Follow up Plan:
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STATIN
|
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Patient on Statin Therapy
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If no, code 4013F - 1P Modifier
|
|
VITALS
|
|
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Temperature
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Height
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Heart Rate
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Weight
|
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Pulse ox
|
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BMI
|
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BMI:
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BMI Coding:
• • •
|
DO NOT FORGET TO CODE
|
|
Was BMI abnormal?
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Follow up Plan:
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|
Exercise Screening:
|
|
|
Do you exercise regularly?
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Duration
|
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Frequency:
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Face to face counseling for obesity, 15 minutes
|
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Advanced Care Planning:
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Date Reviewed
|
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Patient has:
• • •
|
|
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Discussed with patient or caregiver?
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Copy of plan in patient's chart?
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Advanced Care Planning coding:
• • •
|
DO NOT FORGET TO CODE
|
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Cognitive Function Assessment:
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|
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Assessed the beneficiary's cognitive function by direct observation, with due consideration of information.
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Depression in Remission at 12 months:
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Did the patient have an active diagnosis of major depression including remission or dysthymia?
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Did the patient have one or more PHQ-9's administered?
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Did the patient have a PHQ-9 score > 9 during an outpatient encounter?
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Date:
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Score:
|
|
Did the patient have one or more PHQ-9s administered 12 months (+/-30 days) after the measurement period?
|
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|
Date
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Score:
|
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Diabetes Mellitus*
|
|
|
Does the patient have a history or active diagnosis of Diabetes?
|
|
|
Last HbA1C:
|
Date
|
|
ICD-10 Diagnosis Code:
|
|
|
A1c coding
• • •
|
DO NOT FORGET TO CODE
|
|
Does the patient have a blood pressure reading below 140/90?
|
|
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Is the patient a user of tobacco?
|
Aspirin use:
|
|
Was the patient screened for diabetic retinal disease or was a negative retinal exam captured? Must have been co
|
|
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Retinopathy
|
Macular Degeneration
|
|
Cataracts
|
|
|
Glaucoma Screening:
|
Date
|
|
Where
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Abnormalities
|
|
Most recent LDL value:
|
Date
|
|
Heart Failure (HF)
|
|
|
Does the patient have a diagnosis of Heart Failure?
|
|
|
If yes, does the patient have LVSD? (LVEF<40% or moderate or severe)
|
|
|
If yes, was the patient prescribed a Beta Blocker?
|
|
|
HF coding
• • •
|
DO NOT FORGET TO CODE
|
|
Cardiovascular Disease
|
|
|
Does the patient have a diagnosis of Atherosclerotic Cardiovascular Disease (active or history of) ?
|
|
|
Has the patient had a fasting or direct LDL > 189mg/Dl?
|
|
|
Date
|
Results
|
|
LDL coding
• • •
|
DO NOT FORGET TO CODE
|
|
Is the patient between 40-75 years old AND a Type 1 or 2 diabetic AND have a fasting or direct LDL-C between 70-189 mg/dL betwe
|
|
|
Is the patient currently a statin user or received a prescription?
|
|
|
Statin coding
• • •
|
If no, code 4013F - 1P Modifier
|
|
Ischemic Vascular Disease (IVD)
|
|
|
Was the patient discharged for an acute myocardial infarction, coronary artery bypass graft or percutaneous coronary
|
|
|
Did patient have an active diagnosis of ischemic vascular disease?
|
|
|
If yes, was the patient prescribed aspirin or another antithrombotic during the measurement period?
|
|
|
IVD coding
• • •
|
DO NOT FORGET TO CODE
|
|
Is the patient's LDL controlled? (<100mg/dL)
|
Was a complete lipid panel completed?
|
|
Coronary Artery Disease (CAD)
|
|
|
Does the patient have an active diagnosis of CAD or history of surgery?
|
|
|
Diagnosis Code:
|
|
|
If CAD does the patient have Diabetes?
|
Diagnosis Code:
|
|
if CAD, does the patient have LVSD? (LVEF<40% or moderate or severe)
|
Diagnosis Code:
|
|
If the patient has Diabetes or LVSD, has the patient been prescribed an ACE inhibitor or ARB therapy?
|
|
|
CAD coding
• • •
|
DO NOT FORGET TO CODE
|
