TCM Note_No contact made

Transitional Care Management Initial Contact Note

Date of admission: [date name="date_of_admission"]

Date of discharge: [date name="date_of_discharge"]

Hospital: [text name="hospital" default="Name of hospital"]

Attending Physician: [text name="attending" default="Attending provider name, if known"]

Reason for Hospitalization: [textarea name="reason" default=""]

Discharge Diagnoses: [textarea name="discharge_diagnoses" default=""]

[checkbox name="Records" value="Records available and uploaded into GehriMed.|Records request sent today."]

Contact attempt #1:[date name="contact_date" default="08/27/2021"]
Number called: [text name="number_called" default="615-999-9999"]
Result: [radio name="Results" value="Voicemail left|Voicemail box was full or not set up|Phone number was disconnected|Phone number is no longer valid"]

Contact attempt #2:[date name="contact_date2" default="08/27/2021"]
Number called: [text name="number_called2" default="615-999-9999"]
Result: [radio name="Results" value="Voicemail left|Voicemail box was full or not set up|Phone number was disconnected|Phone number is no longer valid"]

The patient has the following NEW medications: [textarea name="New_meds" default="Unable to determine, patient and records not available."]
The following medications were stopped: [textarea name="Stopped_meds" default="Unable to determine, patient and records not available."]

Pending Labs and Imaging Studies: [textarea name="pending_findings" default="Unable to determine, patient and records not available."]

Recommended Outpatient Evaluations/Appointments: [textarea name="outpatient_evaluations" default="Unable to determine, patient and records not available."]

Home health agency: [textarea name="Home_Health" default="Unable to determine, patient and records not available."]

Scheduled TCM Provider Visit: [date name="date_of_visit"]
Transitional Care Management Initial Contact Note

Date of admission:

Date of discharge:

Hospital:

Attending Physician:

Reason for Hospitalization:

Discharge Diagnoses:



Contact attempt #1:
Number called:
Result:

Contact attempt #2:
Number called:
Result:

The patient has the following NEW medications:
The following medications were stopped:

Pending Labs and Imaging Studies:

Recommended Outpatient Evaluations/Appointments:

Home health agency:

Scheduled TCM Provider Visit:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.42, 19 form elements, 58 boilerplate words, 4 text boxes, 7 text areas, 5 dates, 1 checkboxes, 2 radio buttons, 20 total clicks
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