CHIPP Follow up Visit

Transcription

1 CHIPP Follow up Visit Use this for a follow up CHIPP Visit. * Required 1. Date of Visit Example: December 15, Participant Code Please do not enter Participant name in this formenter in Practice Fusion. 3. Visit Time In Example: 8:30 AM 4. Visit Time Out Example: 8:30 AM 5. Total Time for Visit (minutes) 6. Total Miles for Visit Complete after in home encounter. Calculate round trip from Station of origin to Participant s home for all encounters evenif other Participants seen on same shift. 7. CHIPP Paramedic Karla Valencia Malki Higuera Alex Green Michael Fielder Ernesto Archuleta Other

2 8. CHIPP Second Team (EMT/Medic) Jenny Jeong JR Manriquez Chris Cruz Other 9. Other CHIPP Personnel Any guests, or CHIPP team member not included in drop down lists above. Not Applicable Participant Assessment: Chronic Conditions

3 10. Medical History Includes * Only include diagnoses by a medical provider at date of encounter. Select all that apply and review applicable CHIPP protocols. Disease specific questions will be needed as applicable. Diabetes (ALL visits: Asthma (Monthly form: COPD (Emphysema/Chronic Bronchitis) ALL visits:

4 CHF (ALL visits: Post MI (Monthly form:

5 Hypertension (ALL visits: None Participant Assessment: Vital Signs Do not hesitate to upgrade to EMS protocols or consult Medical Direction if any Participant data indicates the need to do so. Vitals should be entered into Practice Fusion/Image Trend CIP as indicated. 11. VS Skin Pink Warm Dry Cool Cold Moist Clammy Hot Flushed Mottled

6 12. VS Lung Sounds Clear, equal bilaterally 13. VS ECG Rhythm NSR Paced 14. Medical Direction Notified? * No, within CHIPP guideline parameters. Yes; Participant upgraded to EMS Yes; Participant refused EMS, continued as CIP encounter Yes; Participant refused EMS, CIP encounter discontinued Yes; EMS refusal and POV to PCP Yes; EMS refusal and POV to ED Other No; outside CHIPP parameters. Upgraded immediately to EMS 15. Medical Direction Notification Note Regular Medical Care 16. Where is your regular Primary Care Provider? This will be asked at each visit to track any changes made by Participant. I do not have one. (Please provide SCC PCP list to Participant, offer support). Mariposa Community Health Center (please link this person to MCHC Care Plus) Carondelet Medical Group. Nogales Medical Clinic. Other

7 17. PCP Note: Provide specific name of PCP or other important notes. 18. When was your last PCP visit? 19. Do you have transportation to PCP visits? Yes No (highlight transportation availability for MCHC patients) 20. Do you have other/specialty healthcare providers? No Home Health Cardiology Nephrology Pulmonology 21. Other/specialty healthcare provider note: 22. PCP Visit Note:

8 23. ED Visit Notes: 24. Since our last CHIPP visit, how many times did you call 911? Call Notes: 26. Since our last CHIPP visit, how many times did an ambulance take you to a hospital emergency department? Include inter facility transports

9 27. Ambulance Transport Notes: 28. Since our last CHIPP visit, how many times were you hospitalized for one night or longer? Do not inlcude ED visits, inpatient stays only Hospitalization Notes: Medications 30. Any changes to medication regimen since last visit? Include over the counter, prescription, herbs, supplements. Medication Inventory is a separate sheet TBD. Yes (changes since last visit, changes made to Medication Inventory in IT/Practice Fusion) No 31. Immunizations current? Enter in Practice Fusion; Under "Immunizations" Medication Adherence (SMAQ)

10 Simplified Medication Adherence Questionnaire completed at each visit. 32. SMAQ1: Do you ever forget to take your medicine? Yes No 33. SMAQ2: Are you forgetful at times about taking your medicine? Yes No 34. SMAQ3: Sometimes if you feel worse, do you stop taking your medicines? Yes No 35. SMAQ4: Thinking about the last WEEK. How often have you not taken your medicine? Never 1 2 times 3 5 times 6 10 times >10 times 36. SMAQ5: Did you not take any of your medicine over the past weekend? Yes No 37. SMAQ6: Over the past 3 MONTHS, how many days have you not taken any medicine at all? 2 days 2 days 38. SMAQ7: Is the Participant adherent to medication according to questions SMAQ1 6? SCORING: A positive response to any of the qualitative questions (SMAQ1, 2, 3, or 5), more than 2 doses missed over the past week (SMAQ4) or over 2 days of non medication during the past 3 months (SMAQ6) signifies non adherence according to the SMAQ.) Yes No (AzPDIC to review)

11 39. Are there any reasons Participant does not take medications as prescribed? Choose any as indicated by Participant. CDC Fall Risk Assessment Hazard follow up from initial Fall Risk Assessessment at each visit. 40. Plan for fall hazard remediation: Please describe plan in next field. None Financial assistance needed for remediation (CHIPP to review resource options). Homeowner referred to USDA Rural Development Grant program. Participant to remedy hazards. 41. Fall hazard remediation note: Based upon initial plan of action. Respiratory Environmental Scan Adapted from EPA Clearing the Air of Asthma Triggers. id=0b_ibvxbntu94nuhtc05ouudxltq 42. Notes from initial Environmental Scan: Stanford Physical Activity Complete at each CHIPP encounter.

12 43. During the past week, even if it was not a typical week for you, how much total time (for the entire week) did you spend on each of the following? One choice for each row. Mark only one oval per row. Stretching or strengthening exercises range of motion, using weights, etc.) Walk for exercise Bicycling (including stationary exercise bikes) Other aerobic exercise equipment (Stairmaster, rowing, skiing machine, etc.) Other aerobic exercise None <30 min min 1 3 hrs >3 hrs 44. Specify other aerobic exercise Chronic Disease Specific Questions Each relevant section will be completed based on CONFIRMED diagnosis of condition by Participant s healthcare provider. Applicable questionnaires may be found: LINK Only complete questionnaires if diagnosis is present by a physician. Please note some questionnaires are only completed at initial and final visit. SOME questionnaires are completed at EACH visit. 45. Disease specific questionnaires completed: NA Diabetes CHF Asthma COPD Recent MI Hypertension Participant Plan Remember MI Principle OARS: Open ended Questions, Affirmation of strengths, Reflective listening, Summary 46. Notes about plan progress from Initial Visit: Resource Linkage Follow up

13 Choose all resources discussed/recommended. Make a note as well about specifics. 47. Resource Linkage Recommendation(s): Please review SCC CHIPP Resouces that may be applicable: id=1nukc56iidsk457x3qwptomvhn5pjwbbxcndr201_ql0 Fall Hazard Remediation MCHC Care Plus (for MCHC patients requiring intensive services or to refer ANYONE to wellness classes) Health Insurance Navigation (for uninsured/underinsured/those with insurance questions) Medication Support Fire Prevention Alzheimer's/Dementia Support Telecare (provides supportive calls to seniors with health concerns) Behavioral Health Support (Nursewise crisis/warmline) Nutrition Support Health Education Physical Activity Household Support Mortgage/Utility/Economic Support Tobacco Cessation 48. Resource Linkage Explanation: Describe resources linked and/or other needs that need to be addressed. Narrative Please complete visit narrative in Practice Fusion to highlight pertinent information from visit. Powered by