Plan

Discussion and Plan
[checkbox name="plan1" memo="Free text plan element" value=""][conditional field="plan1" condition="(plan1).is('')"]1. [textarea cols="30" name="Plan_1" default="first plan element"]
[/conditional][checkbox name="plan2" memo="Free text plan element" value=""][conditional field="plan2" condition="(plan2).is('')"]2. [textarea cols="30" name="Plan_2" default="2nd plan element"]
[/conditional][checkbox name="plan3" memo="Free text plan element" value=""][conditional field="plan3" condition="(plan3).is('')"]3. [textarea cols="30"  name="Plan_3" default="3rd plan element"]
[/conditional][checkbox name="plan4" memo="Free text plan element" value=""][conditional field="plan4" condition="(plan4).is('')"]4. [textarea cols="30"  name="Plan_4" default="4th plan element"]
[/conditional][checkbox name="plan5" memo="Free text plan element" value=""][conditional field="plan5" condition="(plan5).is('')"]5. [textarea cols="30" name="Plan_5" default="5th plan element"]
[/conditional][checkbox name="plan6" memo="Free text plan element" value=""][conditional field="plan6" condition="(plan6).is('')"]6. [textarea cols="30" name="Plan_6" default="6th plan element"][/conditional][remark] 


Diabetes Management 


[/remark][checkbox name="planDM" memo="Diabetes Plan Preformatted" value=""][conditional field="planDM" condition="(planDM).is('')"][select name="linenumber_other1" value="1. |2. |3. |4. |5. |6. |7. |8. |9. |10. |"][select value="Type 2|Type 1|"] diabetes[checkbox value=", newly diagnosed"]: 
- [select value="Initiate|Continue"] complication prevention program, including: [checkbox value="pneumonia Vaccination|yearly vaccination with Influenza|foot care instruction|yearly foot exam|podiatry referral|foot and skin ulcer surveillance quarterly|yearly ophthalmic retinal monitoring/exam|quarterly chemistry, lipid, and A1c monitoring|yearly urine microalbumin monitoring|dietary surveillance and counselling|blood pressure monitoring|preconception counseling"]
- Self monitoring: The patient will perform home blood glucose testing [select value="once a day|twice a day|three times a day|four times a day|once a week|twice a week|three times a week|at no specific times|at clinic visits"].
- The patient's goals for diabetes control are:
[checkbox value="Morning (fasting) blood sugar less than 130. "][checkbox value="Blood sugar prior to meals of 80-120. "][checkbox value="Bedtime blood sugar less than 120.  
 "][checkbox value="Hemoglobin a1c less than 7 without significant symptoms. "][checkbox value="Hemoglobin a1c less than 8. "][checkbox name="control" value="Other: "] [/conditional][conditional field="control" condition="(control).is('Other: ')"][text default="diabetes control details" size=140].
[/conditional][conditional field="planDM" condition="(planDM).is('')"]- Insulin therapy [select name="insulin" value="is not indicated at this time|with long-acting insulin only will be initiated|with long- and short-acting insulin will be initiated|with long- and short-acting insulin will be continued|with long-acting insulin only will be initiated|with long-acting insulin only will be continued"] [text memo="other insulin plan"][/conditional][conditional field="planDM" condition="(planDM).is('')"][conditional field="insulin" condition="(insulin).is('with long-acting insulin only will be initiated')||(insulin).is('with long- and short-acting insulin will be initiated')"][checkbox value="The patient will not adjust insulin. "][/conditional][conditional field="insulin" condition="(insulin).is('with long- and short-acting insulin will be initiated')"][checkbox value="The patient will adjust short-acting insulin based on glucose checks before meals. "][/conditional][conditional field="insulin" condition="(insulin).is('with long-acting insulin only will be initiated')||(insulin).is('with long- and short-acting insulin will be initiated')"][checkbox value="The patient adjusts short-acting insulin based on carbohydrate counting. "][/conditional][conditional field="insulin" condition="(insulin).is('with long-acting insulin only will be initiated')||(insulin).is('with long- and short-acting insulin will be initiated')"][checkbox value="The patient will adjust long-acting insulin based on fasting glucose trend. "]  [link url="https://www.soapnote.org/patient-education/drgfms-care-plan-3x3-4x4-insulin/" memo="3 by 3/4 by 4 long-acting insulin adjustment instruction for patients"][/conditional][conditional field="planDM" condition="(planDM).is('')"][textarea memo="freetext plan elements"][/conditional][remark] 


Medication Management 


[/remark][checkbox name="med_management" memo="medication management" value=""][conditional field="med_management" condition="(med_management).is('')"][select name="linenumber_med_management" value="1. |2. |3. |4. |5. |6. |7. |8. | 9. |10. "] Medication management: [checkbox name="discontinue" value="Discontinue therapy with "][/conditional][conditional field="discontinue" condition="(discontinue).is('Discontinue therapy with ')"][textarea cols="30" rows="3"]. [/conditional][conditional field="med_management" condition="(med_management).is('')"][checkbox name="initiate" value="Initiate therapy with "][/conditional][conditional field="initiate" condition="(initiate).is('Initiate therapy with ')"][textarea cols="30" rows="3"]. [/conditional][conditional field="med_management" condition="(med_management).is('')"][checkbox name="adjust" value="Adjust therapy with "][/conditional][conditional field="adjust" condition="(adjust).is('Adjust therapy with ')"][textarea cols="30" rows="3"]. [/conditional][conditional field="med_management" condition="(med_management).is('')"][checkbox name="continue" value="Continue therapy with "][/conditional][conditional field="continue" condition="(continue).is('Continue therapy with ')"][textarea cols="30" rows="3" default="all other previously prescribed meds"]. [/conditional][remark] 


Lab orders and diagnostic studes 


[/remark][checkbox name="labs_studies" memo="Labs and Diagnostic Studies" value=""][conditional field="labs_studies" condition="(labs_studies).is('')"][select name="linenumber_labs_dx" value="1. |2. |3. |4. |5. |6. |7. |8. | 9. |10. "][select name="labs_reason" value="|Labs for disease monitoring|Labs for medication monitoring|labs for assessment of |Labs for diagnosis of "][text]: [frontload soapnote="samples/drgfms-lab-picklist/"]
[textarea cols=50 default="No other imaging or other diagnostic studies indicated at this time."][/conditional][remark] 


Smoking Discussion 


[/remark][checkbox name="smoking" memo="Smoking Discussion" value=""][conditional field="smoking" condition="(smoking).is('')"][select name="linenumber_smoking" value="1. |2. |3. |4. |5. |6. |7. |8. | 9. |10. "]Tobacco abuse: Verified current smoking status. Tobacco cessation strongly encouraged. Discussed the need to quit smoking, including a detailed discussion of the cardiopulmonary and other chronic disease it causes. Assessed the patient's readiness to quit.  Offered assistance with referral to community resources for smoking cessation or pharmacologic therapy. We will reassess at next visit. 10 minutes was spent in tobacco cessation counselling. [/conditional][remark] 


Plan discussion


[/remark][select memo="discussion line number" name="linenumber_discussion" value="1. |2. |3. |4. |5. |6. |7. |8. |9. |10. |"][checkbox value="Discussed evaluation, treatment and usual course, including potential adverse effects of all therapies. "][checkbox value="Discussed return criteria and red flags which should prompt seeking emergency department care. "][checkbox value="All questions were answered. "]Explained the above assessment and plan to patient. Patient [select name="patientagreement" value="acknowledged understanding and intent to follow through with plan.|disagrees and prefers a second opinion.|wishes to think about recommendations.|agrees with some recommendations but has reservations about others."] [textarea cols="30" rows="2" memo="details"]
[select memo="follow-up plan line number" 
 name="linenumber_followup" value="2. |3. |4. |5. |6. |7. |8. |9. |10.|"] [checkbox name="schedule" memo="Schedule follow-up" value=""][conditional field="schedule" condition="(schedule).is('')"]Follow up in [select name="followup_number" value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"] [select name="followup_unit" value="months|days|weeks|years"]. 
[/conditional][checkbox value="Follow up at previously scheduled appointment."] [checkbox name="labs_schedule" value="Obtain blood tests at lab prior to visit. "][checkbox name="labsnow" value="Obtain labs ASAP. "][checkbox name="notification" value="Will notify patient of lab or study results and any changes to care plan that result. Patient instructed to call office if no communication is received within 72 hours of lab draw or study completion."]

[comment memo="coding blurbs"][checkbox value="-The above SocHx/Allergies/Meds/PMHx/PSHx/FMHx were reviewed & updated at today's visit.
"][checkbox value="-The scribe/medic/nurse/student assisted in collecting and documenting the patient's history.
-I have personally reviewed it and verified its accuracy.
"][checkbox value="-The scribe/medic/nurse/student assisted in documenting the physical exam performed by me.
-I have personally reviewed it and verified its accuracy.
"][checkbox value="-Laboratory results as displayed were reviewed and interpreted
"][checkbox value="-Radiologic study results as displayed were reviewed and interpreted
"][checkbox value="-Radiologic study images which results are displayed in note were reviewed and interpreted
"][checkbox value="-Pap smear was performed and sample collected at today's visit, sample to be sent to lab for analysis
"][conditional field="APvirtualblurb" condition="(APvirtualblurb).is('Virtual Encounter ')"]
[/conditional][checkbox name="APvirtualblurb" memo="*" memo_color="blue" memo_size="small" value="Virtual Encounter"]
[conditional field="APvirtualblurb" condition="(APvirtualblurb).is('Virtual Encounter')"] - Spent [text size="5"] minutes via [select value="realtime audio/video communication|voice-only/telephone|asynchronous secure text messaging"] involving obtaining/reviewing history, [checkbox value="conducting visual exam|discussing test results|discussing workup|discussing above plan|patient education"]
[/conditional]