TCM Nurse Note_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=""] [select name="Records" value="Records available and uploaded into GehriMed.|Records request sent today."] Date of Initial Contact:[date name="contact_date" default="08/27/2021"] Spoke with:[comment memo="Check all that apply"][checkbox name="Contact_Person" value="Patient|Patient's power of attorney|Patient's primary caregiver|Facility nurse responsible for patient"] Medication reconciliation was performed today. The patient has the following NEW medications:[textarea name="New_meds" default="No new medications."] The following medications were stopped:[textarea name="Stopped_meds" default="No medications were stopped."] [select name="Med_Issues" value="The patient has no problems or concerns with current medications.|The patient has problems or concerns with medications, message sent to provider."][text name="Med_Problems" memo="Description of medication problems, leave blank if none"] [select name="Med_Issues" value="The patient denies needing prescriptions or refills at this time.|The patient needs a prescription for medication, message sent to provider."][text name="Med_Needs" memo="Medications needed, leave blank if none"] Pending Labs and Imaging Studies: [textarea name="pending_findings" default="No studies or lab results were pending at the time of discharge."] Recommended Outpatient Evaluations/Appointments: [textarea name="outpatient_evaluations" default="No outpatient appointments were recommended."] Home health services: [select name="HH_Services" value="The patient was referred to home health and services have started.|The patient was referred to home health, awaiting initial assessment.|The patient was not referred to home health."][text name="Agency_Name" memo="Name of home health agency, leave blank if none"] We reviewed the hospital discharge instructions together. The patient and/or caregiver was given the opportunity to ask questions. Summary of transition: [textarea name="Transition_summary" memo="How is the patient handling their transition home? Do they feel their condition is stable enough to be safe at home?"] [checklist name="Issues" value="The patient has new or unresolved symptoms that require urgent attention, message sent to provider.|The patient has a need for DME equipment, message sent to provider.|The patient and/or caregiver have questions not able to be answered at this time, message sent to provider.|The patient needs assistance with scheduling follow-up appointments, assistance provided.|The patient and/or caregiver has no additional questions or concerns at this time."] [text name="Issue_Summary" memo="Summazrize issues here, leave blank if none"] Scheduled TCM Provider Visit: [date name="date_of_visit"]
There are 24 form elements.
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Sandbox Metrics: Structured Data Index 0.43, 24 form elements, 81 boilerplate words, 6 text boxes, 7 text areas, 4 dates, 1 checkboxes, 1 check lists, 4 drop downs, 1 comments, 30 total clicks
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