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enhanced care management documentation checklist medical

Verify patient's demographic details (name, age, gender, etc.)

Record the patient's medical history and any relevant past treatments

Document the patient's current medical conditions and diagnoses

Include information about the patient's primary care physician or specialist

List all prescribed medications, including dosage and frequency

Note any over-the-counter medications or supplements the patient is taking

Document any allergies or adverse reactions to medications

Summarize the patient's personalized care plan, including goals and objectives

Include details about any ongoing treatments or therapies

Specify any necessary lifestyle modifications or dietary restrictions

Attach or reference recent lab results, diagnostic test reports, and imaging studies

Record any abnormal findings or significant changes in the patient's health status

Document any conversations or consultations with other healthcare providers involved in the patient's care

Include any recommendations, referrals, or follow-up actions discussed with the care team

Record any education provided to the patient or their family regarding their condition and treatment options

Obtain written consent for procedures, surgeries, or any major interventions

Document any significant changes or updates regarding the patient's condition

Include details about the patient's response to treatments and any observed improvements or setbacks

Outline the plan for any necessary follow-up appointments or referrals

Provide instructions for post-discharge care, including medication changes or home healthcare arrangements

Please note that this is just a sample checklist, and the specific requirements may vary depending on the healthcare facility or organization.

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