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TODAY'S PROVIDER
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DO NOT FILL OUT ANYMORE!!!
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MEDICATION REVIEW & MEDICAL PROBLEMS
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Medications & Medical Problems (use dictation, e.g. "lisinopril for HTN")
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Medication Review (check all that apply):
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Medication Adherence
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Medications reconciled with patient/caregiver (CPT2)
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No new medications prescribed on this visit. (defaulted)
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I have personally reviewed patient medication list. (defaulted)
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TOBACCO, ALCOHOL, SUBSTANCE USE
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Tobacco Use
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Do you smoke?
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If you smoke, how much do you smoke?
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If patient smokes, was smoking cessation discussed?
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Do you have a smoker's cough?
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Do you get chronic bronchitis?
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Describe cough symptoms:
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Alcohol Use
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Have you had or currently have dependency on alcohol?
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If yes, during your dependency, what symptoms did you experience?
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When was your last drink?
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Clinician Notes:
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Substance Use
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In the past or currently, have you been dependent on any of the following substances/drugs?
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If yes, during your dependency, what symptoms did you experience?
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When did you use last?
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Clinician Notes:
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SUBSTANCE USE DISORDER SCREENING
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Turn "ON" if pt. has alcohol/substance dependency.
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1. Are you taking the alcohol or substance in larger amounts and for longer than intended
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2. Are you wanting to cut down or quit but not being able to do it?
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3. Are you spending a lot of time obtaining the alcohol or drugs?
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4. Are you craving or strong desire to use alcohol or drugs?
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5. Are you repeatedly unable to carry out major obligations at work, school, or home due to substance use?
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6. Do you continue use despite persistent or recurring social or interpersonal problems caused or made worse by substance use?
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7. Do you stop or reduce important social, occupational, or recreational activities due to substance use?
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8. Do you have recurrent use of substance in physically hazardous situations?
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9. Consistent use of substance despite ack. of persistent/recurrent physical or psych difficulties from from using substance
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10. Tolerance defined by needing increased amts to achieve intoxication/diminished effect
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11. Do you have manifest withdrawal as either characteristic syndrome or the substance is used to avoid withdrawal?
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Severity Criteria for SUD:
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Substance Related Issues
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LIVER/COLON DISEASE
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Have you ever been treated for liver disease, cirrhosis, or Hepatitis B/C?
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If yes, clinician notes:
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Have you ever been treated for Crohn's disease, ulcerative colitis, or pancreatitis?
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Do you currently have a colostomy bag or any other tubes coming from your body?
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If yes, clinician notes:
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DEPRESSION SCREENING (PHQ2/PHQ9)
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In the past month, have you often been bothered by feeling down, depressed, or hopeless?
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In the past month, have you often been bothered by having little interest in doing things?
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If yes to either, please explain.
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PAST HISTORY OF TREATED DEPRESSION
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Have you ever been treated for depression by a physician or other type of clinician?
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Notes Section
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Depression Screening Completed (defaulted to ON, CPT2 Code)
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If patient answers yes to either question, tap on PHQ9 button.
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PHQ-9
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1. Little interest or pleasure in doing things
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2. Feeling down, depressed, or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself or that you have let yourself or family down
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7. Trouble concentrating on things, such as reading the newspaper or watching TV
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8. Moving or speaking so slowly that other people could notice or being fidgety or restless
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9. Thoughts that you would be better off dead, or of hurting yourself
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Does the patient have at least 5 of the 9 symptoms above?
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If YES, consider Dx of Major Depression
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If NO, consider unspecified adjustment disorder.
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Add numbers in ( ) for PHQ9 Total Score
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TOTAL PHQ-9 SCORE
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Depression Severity Results
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COLORECTAL CANCER SCREENING (ages 50-75 yrs only)
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Have you had a colonoscopy in the last 9 years or other colon screenings?
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If yes, when did you have it? (year is sufficient)
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History of Colon Cancer?
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Recommended Fecal Occult Blood test yearly + sigmoidoscopy every 5 years
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BREAST CANCER SCREENING (ages 50-74 yrs)
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Turn On for Breast Cancer Screening, if applicable.
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Have you had a mammogram in the last 27 months (2 yrs, 3 months)
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If yes, when did you have it? (year is sufficient)
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History of Bilateral Mastectomy?
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If yes, please explain:
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PROSTATE CANCER SCREENING (Males 50+ or high risk 40+)
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Turn On for Prostate Cancer Screening (Male), if applicable.
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Recommendation for PSA
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GLAUCOMA SCREENING
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Recommendation for Glaucoma Test
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SPECIALISTS PATIENT IS SEEING
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Patient is seeing following specialist(s):
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If other, what type of specialist?
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CLINICAL QUALITY MEASURES
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BMI Assessment
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BMI Value (auto-filled)
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Co-Morbidities
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BMI Value 40+ or without Co-Morbidities
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BMI Value 35+ for Morbid Obesity with Co-Morbidities
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BMI Result
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BMI Assessed and Documented
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Blood Pressure
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Blood Pressure (auto-filled)
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Systolic (CPT2 Codes)
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Diastolic (CPT2 Codes)
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OTHER CHRONIC CONDITIONS
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Have you ever been told you are diabetic?
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Have you ever taken medication for diabetes?
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Do you have a nitroglycerin prescription for angina/chest pain?
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Do you have a prescription inhaler to use for respiratory illness?
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Do you use home oxygen?
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Have you ever had an organ transplant?
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Do you have a pacemaker?
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If yes to pacemaker, why was it placed?
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Do you have neuropathy?
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Do you have bruising on your forearms?
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Notes:
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Diabetic Patient
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Turn On for Diabetic Patients
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Do you have any diabetic wounds or ulcers?
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Have you had amputations? (toes, foot, leg...)
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If yes to amputation, do you have phantom pain?
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Are you on dialysis?
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Do you take insulin?
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LDL Lab Status (recommended yearly)
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GFR or Microalbumin Lab Status
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HbA1C Lab Status (drops billing code & action)
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Date of Last HbA1C Test
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HbA1C Lab Value
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HbA1C Control Status (CPT2)
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Diabetic Retinal Exam
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Diabetic Retinal Exam Status (Turn On if completed today)
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Do you use eye drops for glaucoma or macular degeneration?
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Diabetic Retinal Exam Status (defaulted)
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Diabetic Nephropathy
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Diabetic Nephropathy Status (Turn On if completed today)
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Is patient on ACE / ARB or Microalbumin being monitored?
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Diabetic Foot Exam
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Diabetic Foot Exam Status (Turn On if completed today)
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Diabetic Foot Exam completed today?
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Foot Exam (check all that apply)
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Assign Foot Risk Category
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Foot Pulses (check all that apply)
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Notes (additional findings):
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Kidney Health Evaluation (KED)
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Kidney Health Evaluation (Turn On if completed today)
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Estimated Glomerular Filtration Rate (eGFR)
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Urine Albumin-Creatinine Ratio (uACR)
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Kidney Health Evaluation for Patients with Diabetes Status
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REVIEW OF SYSTEMS
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CONST
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Notes
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EYES
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Notes
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ENMT
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Notes
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CV
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Notes
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RESP
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Notes
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GI
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Notes
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GU
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Notes
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MUSC
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Notes
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SKIN
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Notes
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PSYCH
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Notes
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NEURO
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Notes
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Other ROS Notes
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All other review of systems are negative (click to on, if applicable)
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PHYSICAL EXAM (all default to normal)
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GEN
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Abnormal
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EYES
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Abnormal
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ENMT
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Abnormal
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NECK
• • •
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Abnormal
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RESP
• • •
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Abnormal
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CARDIO
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Abnormal
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GI
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Abnormal
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MUSCULOSKELETAL
• • •
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Abnormal
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SKIN
• • •
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Abnormal
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PSYCH
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Abnormal
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NEURO
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Abnormal
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Clinician Notes
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ADVANCE CARE PLANNING
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Do you have an Advance Directive or Physician or Medical Orders for Life Sustaining Treatment (POLST/MOLST))
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If yes, which of the following do you have?
• • •
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Advance Care Planning for healthcare discussed? (defaulted to Yes)
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Was Advance Directive/POLST form completed today?
• • •
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QUANTAFLO OR PADCHEK / Peripheral Artery Disease Screening
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QUANTAFLO Results
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Turn ON if QUANTAFLO TEST COMPLETED TODAY
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Right Foot Results and Recommendations
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Left Foot Results and Recommendations
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PADCHEK Results
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Turn ON if PADCHEK TEST COMPLETED TODAY
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Right ABI Results and Recommendations
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Left ABI Results and Recommendations
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Is PAD present?
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Has patient tested positive for Peripheral Artery Disease?
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DPN / MONOFILAMENT Results
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Turn ON if DPN TEST CONDUCTED TODAY
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Monofilament / DPN Test Abnormal?
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SPIROMETRY TEST
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Turn ON if SPIROMETRY TEST CONDUCTED TODAY
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Test Quality for COPD or Other Airway Disease
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PATIENT CONSENT
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Patient Consent
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Patient consent given for (DO NOT choose telemedicine for In Home/Clinics):
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Start Time
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End Time
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Vitals Obtained
• • •
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ASSESSMENT & PLAN
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1. Assessment & Plan
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2. Assessment & Plan
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3. Assessment & Plan
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4. Assessment & Plan
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5. Assessment & Plan
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6. Assessment & Plan
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7. Assessment & Plan
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8. Assessment & Plan
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9. Assessment & Plan
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10. Assessment & Plan
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11. Assessment & Plan
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12. Assessment & Plan
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13. Assessment & Plan
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14. Assessment & Plan
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REFERRALS / CONCERNED PT ENCOUNTER
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TURN ON for Referrals & Concerned Pt. Encounter
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Notes to PCP:
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Unable to diagnose, needs f/u:
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Quantaflo Results Attachment
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Spirometry Results Attachment
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Diabetic Retinal Exam Attachment
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Diagnostic/CT/Echo/Other Attachments
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