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Fall Risk Screening
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Fall Risk Screening
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Date
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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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Have you suffered a fracture or broken a bone due to a fall?
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FRA not completed for medical reasons
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Medication Reconciliation at every visit
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Medication Reconciled
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Date
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Breast Cancer Screening
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Last Mammogram
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Date:
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Colorectal Cancer
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Diagnosis of past history of total colectomy or colorectal cancer?
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If No, has an FOBT been completed in 2024?
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Date:
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FOBT coding
• • •
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DO NOT FORGET TO CODE
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Has a flexible sigmoidoscopy been completed in the last 5 years?
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Date:
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Has a colonoscopy been performed in the past 10 years?
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Date:
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Was the Cologuard test completed in the past 3 years?
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Date:
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Influenza/Pneumonia
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Did patient receive a flu shot from 8/1/2023-3/31/2024
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Date:
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Has the patient ever received a Pneumococcal vaccination?
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Date:
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Body Mass Index
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BMI recorded Result
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Date:
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BMI Coding:
• • •
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DO NOT FORGET TO CODE
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If BMI was outside of normal range (23>x>30) was a follow up plan documented?
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Tobacco Screening
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Has the patient been screened for tobacco use at least once in 2023 or 2024 AND identified as a tobacco user?
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Tobacco Screen Negative
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Tobacco Screen Positive
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If yes, did the patient receive tobacco cessation counseling, which includes brief counseling (3m or less) and/or pharmacotherap
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Patient counseled
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Tobacco Screening
• • •
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Depression
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Has a PHQ-9 been administered to screen for clinical depression in 2024?
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Date:
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Tested
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Little interest or pleasure in doing things
• • •
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Feeling down, depressed or hopeless
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Trouble falling or staying asleep, or sleeping too much
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Feeling tired or having little energy
• • •
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Poor appetite or overeating
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Feeling bad about yourself- or that you are a failure or have let yourself down
• • •
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Trouble concentrating on things, such as reading the newspaper or watching television
• • •
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Moving/ speaking slowly or being fidgety/ restless
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SI/ HI
• • •
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Total Score:
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Depression Screen: Positive or Negative?
• • •
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If positive, was a f/u plan documented in 2024?
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Date:
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Depression in Remission at 12 months
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Did patient have an active diagnosis of major depression including remission or dysthymia from 12/1/22 - 11/30/23?
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Did patient have one or more PHQ-9s administered between 12/1/22 - 11/30/23?
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Did the patient have a PHQ-9 score >9 during an outpatient encounter between 12/1/22 - 11/30/23?
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Date:
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Total Score:
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Did the patient have one or more PHQ-9s administered 12 months (+/-30 days) after measurement period?
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Date:
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Total Score:
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Hypertension (HTN)
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Was patient screened for high blood pressure in 2024?
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If YES, most recent BP reading:
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Date:
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Blood Pressure
• • •
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If not in normal range (systolic >120 & <139 or >80 & <89) was a recommended f/u plan documented?
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Did the patient have a documented diagnosis of HTN by 7/1/23 or any time prior to 12/31/21 but does not end before 1/1/2022?
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Diabetes Mellitus
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Does the patient have a history or active diagnosis of Diabetes in 2023 or 2024?
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ICD-10 Diagnosis Code:
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Last HbA1c:
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Date:
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Result
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Was the patient screened for diabetic retinal disease in 2024?
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Was a negative retinal exam captured in 2024?
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The exam must be performed or reviewed by an ophthalmologist or optometrist.
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Heart Failure (HF)
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Does the patient have a diagnosis of Heart Failure any time prior to 12/31/2024?
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If yes, does the patient have LVSD? (LVEF<40% or moderate or severe)
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If yes, was the patient prescribed a Beta Blocker in 2024?
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Cardiovascular Disease
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1. Does the patient have a diagnosis of Atherosclerotic Cardiovascular Disease from 12/31/24? If yes, proceed to question #4.
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2. Has the patient had a fasting or direct LCL >189mg/dl?
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Date:
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Result
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Is the patient between 40-75 years AND a Type 1 or Type 2 diabetic AND a fasting or direct LDL-C 70-189 from 1/1/23-12/31/24?
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Date:
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Result
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4. Is the patient currently a statin user or received a prescription for a statin during 2024?
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Ischemic Vascular Disease (IVD)
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Was the patient discharged for an acute myocardial infarction, coronary artery bypass graft or percutaneous coronary
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in the 12 months prior to 2022 or have an active diagnosis of ischemic vascular disease during 2024?
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If yes, was the patient prescribed aspirin or another antithrombotic during the measurement period?
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Coronary Artery Disease (CAD)
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Does the patient have an active diagnosis of CAD or history of cardiac surgery through 12/31/2024?
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If CAD, does the patient have Diabetes?
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If CAD, does the patient have LVSD? (LVEF<40% or moderate or severe)
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If the patient has Diabetes or LVSD, has the patient been prescribed an ACE inhibitor or ARB therapy?
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CODE: G0136 for Social questions
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Food
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Within the past 12months, did you worry that your food would run out before you got money to buy more?
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Within the past 12 months, did the food you bought just not last and you didn't have money to get more?
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Housing/Utilities
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Within the past 12 months, have you ever stayed: outside, in a car, in a tent, in a shelter, or someone else's home?
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Are you worried about losing your house?
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Within the past 12 months, have you been unable to get utilities (heat, electricity) when it was really needed?
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Transportation
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Within the past 12 months, has a lack of transportation kept you from medical appts or from doing things needed for daily living
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Interpersonal Safety
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Do you feel physically or emotionally unsafe where you currently live?
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Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by anyone?
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Within the past 12 months, have you been humiliated or emotionally abused by anyone?
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Optional: Immediate Need
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Are any of your needs urgent? Food, a place to sleep for tonight? Afraid you will get hurt if you go home today?
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Would you like help with any of the needs that you have identified?
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