Plan – Medicare personalized plan of service

Medicare preventive services--Personalized Plan of Service [checkbox name="variable_1" value="for" memo="click to include pt name"] [conditional field="variable_1" condition="(variable_1).is('for')"] [text memo="patient name"][/conditional]

[checkbox name="field_1" value="Abdominal aortic aneurysm screening (covered only if ordered at time of IPPE)"][conditional field="field_1" condition="(field_1).is('Abdominal aortic aneurysm screening (covered only if ordered at time of IPPE)')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_2" value="Alcohol misuse screening and counseling"][conditional field="field_2" condition="(field_2).is('Alcohol misuse screening and counseling')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_3" value="Annual Wellness Visit (AWV) - includes health risk assessment and a personalized prevention plan of service (PPPS); first visit 11 full months after IPPE and subsequent visit 11 full months after first or most recent AWV"][conditional field="field_3" condition="(field_3).is('Annual Wellness Visit (AWV) - includes health risk assessment and a personalized prevention plan of service (PPPS); first visit 11 full months after IPPE and subsequent visit 11 full months after first or most recent AWV')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_4" value="Bone mass measurements"][conditional field="field_4" condition="(field_4).is('Bone mass measurements')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_5" value="Breast cancer screening - mammogram"][conditional field="field_5" condition="(field_5).is('Breast cancer screening - mammogram')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_6" value="Cardiovascular disease screening laboratory tests - Lipid panel"][conditional field="field_6" condition="(field_6).is('Cardiovascular disease screening laboratory tests - Lipid panel')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_7" value="Cardiovascular disease - intensive behavioral therapy"][conditional field="field_7" condition="(field_7).is('Cardiovascular disease - intensive behavioral therapy')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_8" value="Cervical and vaginal cancer screening - Pelvic and breast exam including Pap smear"][conditional field="field_8" condition="(field_8).is('Cervical and vaginal cancer screening - Pelvic and breast exam including Pap smear')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_9" value="Colorectal Cancer Screening - Fecal occult blood test; flexible sigmoidoscopy; colonoscopy; stool-based DNA and fecal occult hemoglobin"][conditional field="field_9" condition="(field_9).is('Colorectal Cancer Screening - Fecal occult blood test; flexible sigmoidoscopy; colonoscopy; stool-based DNA and fecal occult hemoglobin')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_10" value="Colorectal cancer screening - Barium enema - patient cost co-pay applies, deductible waived"][conditional field="field_10" condition="(field_10).is('Colorectal cancer screening - Barium enema - patient cost co-pay applies, deductible waived')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_11" value="Depression screening"][conditional field="field_11" condition="(field_11).is('Depression screening')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_12" value="Diabetes screening - glucose testing"][conditional field="field_12" condition="(field_12).is('Diabetes screening - glucose testing')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_13" value="Diabetes self-management training - patient cost 20% after deductible (program accredited by the American Diabetes Association, American Association of Diabetes Educators or the Indian Health Service)"][conditional field="field_13" condition="(field_13).is('Diabetes self-management training - patient cost 20% after deductible (program accredited by the American Diabetes Association, American Association of Diabetes Educators or the Indian Health Service)')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_14" value="Glaucoma test -patient cost 20% after deductible"][conditional field="field_14" condition="(field_14).is('Glaucoma test -patient cost 20% after deductible')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_15" value="Hepatitis B vaccine"][conditional field="field_15" condition="(field_15).is('Hepatitis B vaccine')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_16" value="Hepatitis C screening test"][conditional field="field_16" condition="(field_16).is('Hepatitis C screening test')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_17" value="HIV screening"][conditional field="field_17" condition="(field_17).is('HIV screening')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_18" value="Influenza vaccination"][conditional field="field_18" condition="(field_18).is('Influenza vaccination')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_19" value="Lung cancer screening - Low dose computed tomography (LD-CT) - This benefit may not yet be available in all locales as facilities must meet specific requirements to provide the service."][conditional field="field_19" condition="(field_19).is('Lung cancer screening - Low dose computed tomography (LD-CT) - This benefit may not yet be available in all locales as facilities must meet specific requirements to provide the service.')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_20" value="Medical nutrition therapy for diabetes or kidney disease (provided by nutritionist or dietician)"][conditional field="field_20" condition="(field_20).is('Medical nutrition therapy for diabetes or kidney disease (provided by nutritionist or dietician)')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_21" value="Obesity screening and intensive behavioral therapy"][conditional field="field_21" condition="(field_21).is('Obesity screening and intensive behavioral therapy')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_22" value="Pneumococcal vaccination"][conditional field="field_22" condition="(field_22).is('Pneumococcal vaccination')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_23" value="Prostate cancer screening - prostate specific antigen (PSA)"][conditional field="field_23" condition="(field_23).is('Prostate cancer screening - prostate specific antigen (PSA)')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_24" value="Sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and/or Hepatitis B"][conditional field="field_24" condition="(field_24).is('Sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and/or Hepatitis B')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
[/conditional][checkbox name="field_25" value="Sexually transmitted infection high intensity behavioral counseling"][conditional field="field_25" condition="(field_25).is('Sexually transmitted infection high intensity behavioral counseling')"]-->[select value="|performed today, due again in 1 year.|recommended this year.|recommended|already completed this year.|scheduled for:|patient declined, will continue to address in follow-up.|not indicated."] [text memo="additional info"]
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