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> enhanced care management documentation CalAim DHS
enhanced care management documentation CalAim DHS
Patient Information
Patient Name
Date of Birth
Address
Phone Number
Medical History
List of chronic medical conditions
Allergies (if any)
Previous surgeries/procedures
Current medications
Care Plan
Primary care physician information
Specialists involved in the care
Care goals and objectives
Care instructions provided to the patient
Care Coordination
Care coordinator contact information
Dates and details of care coordination meetings
Communication with other healthcare providers
Referrals made
Assessments and Documentation
Initial assessment findings
Subsequent assessments and updates
Documentation of patient progress
Any changes in the care plan
Medication Management
Medication list and dosages
Medication adherence monitoring
Any medication changes or adjustments
Documentation of side effects or adverse reactions
Care Transitions
Hospital admissions and discharges
Home health services provided
Rehabilitation or skilled nursing facility stays
Follow-up appointments scheduled
Patient Education
Topics covered during patient education sessions
Educational materials provided
Patient's understanding of the information
Any additional resources recommended
Caregiver Support
Identification of primary caregiver
Assessment of caregiver's needs and concerns
Supportive services provided to the caregiver
Documentation of caregiver education
Care Evaluation and Outcomes
Evaluation of the effectiveness of the care plan
Patient satisfaction survey results
Changes made to the care plan based on evaluation
Documentation of patient outcomes and improvements.
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