Get in touch with your patient.This checklist can help streamline the consultation process and ensure comprehensive care for patients with chronic conditions. Open Form CCM Patient Office Note Date MM DD YYYY Patient Name First Name Last Name Date of Birth MM DD YYYY Review medical history (chronic conditions, previous treatments) * Check box once confirm N/A Update contact information and emergency contacts Preliminary Assessment * Review vital signs (blood pressure, heart rate, weight) Please check box once confirmed N/A Check laboratory results (e.g., blood glucose, lipid panel) * Please check box once confirmed N/A Assess current medication list (adherence and side effects) * Please check box once confirmed N/A Chronic Condition Management * Discuss current management plan for each chronic condition Please check box once confirmed N/A Evaluate symptom control and any new issues * Please check box once confirmed N/A Review lifestyle factors (diet, exercise, smoking, alcohol use) * Please check box once confirmed N/A Goals of Care Establish short-term and long-term goals with the patient Prognosis Please explain Discuss advance care planning, if applicable Please check box once confirmed N/A Address patient preferences and values regarding treatment * Please check box once confirmed N/A Medication Management * Review appropriateness of current medications Please check box once confirmed N/A Identify potential drug interactions and contraindications * Please check box once confirmed N/A Ensure medications align with clinical guidelines * Please check box once confirmed N/A Care Coordination * Identify interdisciplinary team members involved in care Please check box once confirmed N/A Discuss referrals to specialists or other providers * Please check box once confirmed N/A Review follow-up schedule and communication preferences * Please check box once confirmed N/A Education and Support * Provide education on chronic disease management Please check box once confirmed N/A Discuss available resources (support groups, educational materials) * Please check box once confirmed N/A Ensure understanding of the care plan and self-management strategies * Please check box once confirmed N/A Documentation * Document patient visit details and any updates Ensure all referrals and follow-up tasks are clearly noted * Please check box once confirmed N/A Follow-Up * Schedule next appointment Please check box once confirmed N/A Confirm patient understands follow-up plan and next steps * Please check box once confirmed N/A Provider Signature/Name * Date * MM DD YYYY Time spent with patient Thank you!
