enhanced care management documentation

Patient Information

Gather patient demographics (name, age, gender, contact information)

Verify patient's insurance information

Obtain patient's medical history and any relevant past medical records

Document any known allergies or sensitivities

Note any language or communication barriers

Care Plan

Review the patient's current care plan

Assess the patient's progress and any changes in their condition

Identify any new goals or objectives for the care plan

Document any modifications or updates to the care plan

Ensure the care plan is aligned with the patient's preferences and needs

Medication Management

List all current medications the patient is taking

Verify medication names, dosages, and frequencies

Document any medication allergies or adverse reactions

Check for any potential drug interactions or contraindications

Note any medication changes or adjustments made during the patient's visit

Health Assessments and Vital Signs

Perform a comprehensive health assessment

Document vital signs including blood pressure, heart rate, temperature, and respiratory rate

Record any abnormal findings or symptoms reported by the patient

Assess the patient's pain level using a standardized pain scale

Capture any relevant physical examination findings

Diagnostic Tests and Results

Document any ordered diagnostic tests and the reason for each test

Track the date and time of test administration

Record the results of each test accurately

Highlight any abnormal or concerning findings

Ensure appropriate follow-up measures are taken based on test results

Care Coordination

Communicate with other healthcare professionals involved in the patient's care

Document any referrals made to specialists or additional services

Coordinate care transitions, such as hospital admissions or discharges

Ensure timely and accurate sharing of information with all involved parties

Follow up on any pending actions or recommendations

Patient Education and Self-Management

Assess the patient's educational needs and health literacy level

Provide relevant educational materials or resources

Teach the patient about their condition, treatment options, and self-care techniques

Document the topics covered during patient education sessions

Encourage patient engagement and involvement in their own care

Follow-Up and Appointments

Schedule any necessary follow-up appointments or referrals

Provide the patient with appointment details and instructions

Document the date, time, and purpose of each follow-up appointment

Ensure the patient understands the importance of attending follow-up visits

Arrange any required transportation or special accommodations

Care Plan Evaluation and Revisions

Evaluate the effectiveness of the care plan based on patient outcomes

Review the patient's progress towards meeting their goals

Identify any barriers or challenges encountered during the care process

Revise the care plan as necessary to address new concerns or changes in the patient's condition

Document any modifications made to the care plan and the reasons behind them