Pulse: Wt: pressure) Cancer; type: convulsionss. Dementia Suicidal ideation Bipolar disorder. Relationship
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1 VITAL SIGNS: BP: Pulse: Temp: Resp.: Ht: Wt: BMI: ALLERGIES (medicines, other): MEDICAL HISTORY: Does patient have/havee history of any of the following (check all that apply)? Amputation; site: Hypertension (high blood pressure) Significant weight changes Asthma Liver disease or hepatitis Cancer; type: Myocardial infarction Congestive Heart Failure Neuropathy COPD /chronic bronchitis Osteoporosis Diabetes Past fracture: Vertebral Hip Wrist GI problems Kidney disease Hemodialysis Glaucoma/other eye problems; Rheumatoid arthritis specify: Hyperlipidemia (highh Seizures or convulsionss cholesterol) Skin condition (ulcers/decubitus) Stroke Surgery; type: Thyroid Problem Transplant; type: Transfusion; Vascular disease; Aortic Peripheral (claudication) Other; specify: SOCIAL/BEHAVIORAL HISTORY: check all that apply Depression Dementia Schizophrenia Suicidal ideation Chronic Anxiety Disorder Bipolar disorder Drug abuse/dependence Alcohol abuse/dependence Smoking: Past Current; # pack-years: FAMILY HISTORY: Please indicate if any person, related byy blood, had any of the following: Condition Relationship Condition Relationship Hypertension Stroke Coronary Artery Disease High cholesterol Diabetes Glaucoma Cancer; type: Alcoholism Asthma Depression/suicide Page 1 of 7
2 REVIEW OF SYSTEMS: Please review with patient and check either Yes or CONSTITUTIONAL EARS/NOSE/THROATT Y N Chills Y N Hearing difficulty/loss Y N Frequent sneezing Y N Daytime drowsiness Y N Ringing in ears (tinnitus) Y N Frequent sore throat Y N Fatigue Y N Frequent ear aches Y N Snoring Y N Fever Y N Ear discharge Y N Recent change in voice Y N Night sweats Y N Attacks of vertigo Y N Sleep apnea Y N Sinus trouble Y N Difficulty in swallowing Y N Nasal blockage Y N se bleeds EYES STOMACH/INTESTINES Y N Wear glasses/ /contacts Y N Ulcer Y N Poor appetitee Y N Cataracts Y N Hiatal hernia Y N Frequent diarrhea Y N Problems with vision Y N Frequent heartburn/indigestion Y N Abnormal stool Y N Blood fromm bowels/rectum Y N Acid reflux Y N Gall bladder attacks/gallstones RESPIRATORY KIDNEYS/URINARY TRACT Y N Cough Y N Bladder infections in past yr. Y N Frequent night urination Y N Shortness of breath Y N Pain/burning w/ urination Y N Kidney stones/infection Y N Coughing up blood Y N Trouble starting urinary stream Y N Blood in urine in past yr. ALLERGY HEART/CIRCULATION Y N Anaphylaxis Y N Chest discomfort (angina) Y N Swelling of legs Y N Food intolerance Y N Shortness of breath w/activity Y N Heart surgery Y N Itching Y N Blood clot in artery/vein Y N Black out spells Y N Nasal congestion Y N Aneurysm of blood vessel Y N Heart murmur Y N Rash Y N Palpitations, racing/pounding heart ENDOCRINE/METABOLISM BLOOD Y N Unusual hair loss/ growth Y N Bleeding/bruisin ng tendency NERVOUS SYSTEM PSYCHOLOGICAL Y N Headache/migrai ine Y N Loss/change in appetite Y N Insomnia Y N Behaviorall change Y N Memory loss Y N Confusion Y N Mood change SKIN MEN Y N Rash/psoriasis/de ermatitis Y N Testicular swelling Y N Frequent urinationn Y N New skin growth or mole Y N Prostate Problems MUSCLES/ /BONES/JOINTS WOMEN Y N Arthritis/other joint disease Y N Painful periods Y N Vaginal Burning Y N Chronic back trouble Y N Excessive flow Y N Irregular cycles Y N Hot flash/menopause symptoms Y N Currently pregnant? LIST CURRENT MEDICATIONS: Current Medications Provider has reviewed all medicationss Please list all prescription/non-prescription medications with dosage/frequency: Page 2 of 7
3 PHYSICAL EXAM Area: NL ABN Describe Findings if Describe Findings if Area: : NL ABN Abnormal Abnormal General Pelvicc Skin HEENT Neck/Thyroid Heart Lungs Breast Abdomen Musculoskeletal Neurologic Vascular Lymphatic Extremities Prostate Rectall PAIN ASSESSMENT 1. Do you have any pain or hurting anywhere now? 2. Have you had any pain or hurting in the last 5 days? Yes Yes 3. If Yes to 1 or 2: When you have pain, where is it? (checkk all that apply, note specific site if requested) Back: Bone: Chest (w/usual activities) Head: Neck Stomach Hip Incisional Other joint: Muscle: Other: 4. Tell me what the pain feels like. (Check all that apply, circle R for radiating or L for localized) Aching Burning R R L L Pressure R L Prickling R L Tingling Tender R L R L Crushing R L Sharp R L Uncomfortable R L Dull R L Sore R L Other: Knawing R L Stabbing R L Numbing R L Throbbing R L 5. How would you rate the intensity for your pain now or during the lastt 5 days on a scale of 1 (mild) to 5 (severe)? 6. How does your pain affect your everyday life? (check all that apply) Sleep Appetite Self Care Activities Ability to bathe/groom/dresss self Nausea Interactions with people Daily Activities Concentrationn Other: 7. What medications have relieved your pain in the past? Page 3 of 7
4 ADVANCE DIRECTIVE ON FILE: Yes; If, discussed with patient? Yes FUNCTIONAL STATUS ASSESSMENT / ADLS (CHECK ALL THAT APPLY Ambulation (check all that apply): Transportation (check all that apply): Drive self Walkk w/o assistance Walker Cane Driven by others Bus/taxi Other: Partiall w/c dependent Complete w/c dependent ne Bedridden Ability to take medication by self: Yes Ability to prepare food: Yes Ability to feed self: Yes Grooming: Yes Have caregiver?: Yes If Yes, type: IHSS Other: Marital Status: Married Divorced Single Homelessness: Yes Toileting: Yes Risk off placement to SNF: Yes If yes, reason: Bladder ncontinence: Yes Risk of admission to hospital: Yes If Yes, discussed w/patient OR pt on Tx during If yes, reason: last 6mos? Yes Risk for Falls: Yes ; If Yes, discussedd w/ patient in last 12 mos? Yes Exercise: Yes; type/ frequency: Preferred language: Other concerns: If, discussed exercise program w/patient: Yes DEPRESSION SCREENER (PHQ-2): Positive if total score= 3 or more, administer PHQ-9 (see attached for PHQ9 test materials) In the past 2 weeks, how often has the patientt been bothered by: 1. Little interest or pleasure in doing things? 2. Feeling down, depressed or hopeless? 3. Total score: Answer Key: t at all=0; Several days=1; More than half the days=2; Nearly every day= =3 Depression Screening Results: Negative screening Pos screening+follow-up plan PHQ-9 Score (if administered) : <10 >=10; indicates major depression; Dx code: ( major depression unspecified, single episode, mild major depression, single episode, moderate major depression, single episode, severe major depression, single episode. Use 296.3X for recurrent episodes) COGNITIVE FUNCTIONING Oriented: Yes Immediatee Recall: Good Poor Delay Recall: Good Poor Memory Deficit: Inappropriate Behavior: Yes Confused: Mostly Yes At times t at All If abnormal in 1 or more, administer Mini-cog; results: Clock Drawing: Memory: Page 4 of 7
5 NUTRITION/WEIGHT ASSESSMENT Check one: BMI above nl range; plan discussedd BMII below nl; plan discussed BMI nl range Recent Weight Change: Yes: increase decrease; amount (%) Time period mos. If weight loss of 10% % in 6 mos or 5% in 3 mos or 2% in 1 mo, considered clinically significant for malnutrition: mild protein-caloriee malnutritionn moderate protein-calorie malnutrition Dietary counseling for weight loss/gain or any nutritional issues? Yess ANNUAL PREVENTIVE SERVICES AND TESTS FOR DIABETICS: : GFR, estimated (serum creatinine) Microalbumin/creatinine ratio result: result : Coding Chronic Kidney Disease Stages 3-5: Coding CKD Stagess 1-2: Stage 3 (585.3): 2 egfr at least 3 mos. apart; Stage 1 (585.1): At least 2 m/c ratio tests>30 at least Stage 4 (585.4): 2 egfr at least 3mos apart; 3mos apart + egfr>90; Stage 5/Renal failure (585.5): egfr <15 / dialysis Stgg 2 (585.2): >= 2 m/c >30 3mos apart + egfr A1c test* result: Most recent A1c <= 9.0 * should be performed at least twice/year Retinal eye exam; Result: rmal non-proliferative retinopathy (362.01) proliferative retinopathy (362.02) vitreous hemorrhage (379.23) LDL-cholesterol; Result: Most recent LDL-cholesterol <100 Most recent BP <130/80 Foot exam w/monofilament test Date: Result: rmal Neuropathy (357.2) LL Skin ulcer (707.10) Absence of foot pulse (PAD; ) OTHER PREVENTIV VE SERVICES/TESTS; check test performed, date performed Flu vaccine in current season (all members); Pt with cardiovascularr condition: LDL-C test; result: Pneumonia Vaccine (one time at 65 yrs of age) ); Most current LDL-C of hypertension: value is <100mg/dL Biennial mammogramm (women aged 40-69); Pt with diagnosis Most recent BP is <140/90 Women 65 yrs+ had bone density test in last 24 mos; Colorectal Screening, age 50+ FOBT(annual); Women with bone fx in last 12 mos had bone density Colonoscopy (every 10 yrs); test OR Rx to treat/prevent osteoporosis; Other test: ; test date/last Rx Glaucoma test by ophthalmologist/optometristt Pt withh rheumatoid arthritis currently on DMARD; (age 65+); last Rx Page 5 of 7
6 DIAGNOSTIC ASSESSMENT AND PLANS Please fill in for each of the pre-populated conditions as well ass all other active/chronic conditions (may add additional pages) HCC Category/ Description ICD9/ /ICD10 Description (also record ICD9/ICD10 Code if available) Service for Assessment Page 6 of 7 Plan
7 DIAGNOSTIC ASSESSMENT AND PLANS (CONT.)) ICD9/ /ICD10 HCC Category/ Description Description (also record ICD9/ICD10 Service for Assessment Code if available) te on Diabetes Complications: Please provide a diagnosis, assessment and plan for both the appropriate 250.XX code AND a separate code for the diabetes complication; for example: Description/ICD9 Code CKD stage 4 (585.4) Diabetes with Nephropathy (250.40) Assessment Stable; last GFR =25 Improving diabetes controll Plan Continue med to control blood pressure Continue ACE inhibitor Plan Page 7 of 7
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