CCP Army Obesity, Metabolic, Pulmonary, CV

Date: [date name="variable_1" default="today"]
Patient Care Plan was updated for the following condition(s): 
[comment memo="The patient has one of the following diagnosis; therefore, the patient requires a Chronic Care Plan documented in their encounter"]

[checklist name="diagnoses" value="Obesity|Metabolic Disorder|Pulmonary Disease|Cardiovascular Disorder"]

Patient Self-Management Assessment: [select name="variable_2" value="Independent |Requires Caregiver support| Requires Case Management"]

Self-Management Resources  [checklist name="variable_3" value="Communication Via Secure Messaging|Handouts|Referrals|Disease Manage classes"]

Duty/Activity Restrictions: [select name="job" value="NONE|See Below"]
[conditional field="job" condition="(job).is('See Below')"]Reason: [text name="Restrictions:"]Start date: [date name="variable_4" default="08/14/2020"] End date: [date name="variable_4" default="08/14/2020"] 
Restrictions: [textarea name="variable_5" default="sample text"][/conditional]

BARRIERS TO ACHIEVING GOALS: [checklist name="barriers" value="Behavioral Health Diagnosis|Social environment|Precontemplative Stage of change|Contemplative Stage of change|Relapse Stage of change|Patient not aligned with treatment plan|Physical limitation|Cognitive limitation|Communication barrier"]

[conditional field="diagnoses" condition="(diagnoses).is('Obesity')"]
Obesity Care Plan 

Definition:
Underweight – <18.5 kg/m2
Normal weight – ≥18.5 to 24.9 kg/m2
Overweight – ≥25.0 to 29.9 kg/m2
Obesity – ≥30 kg/m2
Class I – 30.0 to 34.9 kg/m2
Class II – 35.0 to 39.9 kg/m2
Class III – ≥40 kg/m2 (also referred to as severe, extreme, or massive obesity)

DIAGNOSIS: Obesity [select name="variable_6" value="Class I|Class II|Class III"]

ACTIONABLE DATA:
Date: [date name="variable_7" default="08/14/2020"]       BMI:[text name="variable_7" default="sample text"]
Date: [date name="variable_8" default="08/14/2020"]       Waist Circumference:[text name="variable_8" default="sample text"]

Modifiable Risk Factor Targets: BMI 20-25

Behavior Change: Reduced calorie diet, regular exercise, behavior modification program 
Drug Therapy: [select name="drug" value="No|Yes, see med rec"] 
Devices: [select name="devices" value="No|Yes, see PSH"] 
Indication for Bariatric Surgery: [select name="indication" value="No|Yes"] 
[comment memo="Candidates for bariatric surgery include adolescents and adults with a BMI ≥40 kg/m2, or a BMI of 35 to 39.9 kg/m2 with at least one serious comorbidity (T2DM, OSA, HTN, HLD, OHS, Pickwickian Syndrome, NAFLD, NASH, Pseudotumor cerebri, Asthma, GERD, Venous stasis disease, Severe Urinary Incontinence, Debilitating Arthritis, Impaired quality of Life, Disqualifications of other surgeries as a result of obesity) who have not met weight loss goals with diet, exercise, and drug therapy"]

Stage of Change/Date: [select name="stage" value="Precontemplation|Contemplation|Preparation|Action|Maintenance|Relapse/Recycle"]
 
COMANAGING TEAM/CONSULTANTS:[checklist name="team" value="Wellness Center|Nutritionist|BHC|Exercise Physiology|Sleep Study|Lifestyle modification class|Bariatric Surgery"]

PATIENT SELF-MANAGEMENT GOALS:[textarea name="variable_1" default="sample text"]

FOLLOW-UP PLAN: [text name="variable_1" default="sample text"]
[/conditional]

[conditional field="diagnoses" condition="(diagnoses).is('Metabolic Disorder')"]
Metabolic Disorders Care Plan  

DIAGNOSIS:[checklist name="variable_1" value="Diabetes|Hypertension|Hyperlipidemia"]  

Date:[date name="variable_1" default="08/14/2020"] Most Recent BP:[text name="variable_1" default="sample text"][checklist name="variable_1" value="home|clinic"] 
Goal BP:[text name="variable_1" default="sample text"] per [text name="variable_1" default="sample text"] guidelines

Date: [date name="variable_1" default="08/14/2020"]	HgA1C:[text name="variable_1" default="sample text"]         
Date: [date name="variable_1" default="08/14/2020"]	BMI:[text name="variable_1" default="sample text"] 
Date: [date name="variable_1" default="08/14/2020"]	Total cholesterol: [text name="variable_1" default="sample text"] LDL: [text name="variable_1" default="sample text"] HDL: [text name="variable_1" default="sample text"] Triglycerides:[text name="variable_1" default="sample text"]

Smoker: [select name="smoker" value="Yes|No"]
Diabetes [select name="DM" value="Yes|No"]
 
Date: [date name="variable_1194" default="08/14/2020"] 10 yr CVD risk:[text name="variable_1193" default="sample text"]% Estimator used: ASCVD 
[link url="http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/" memo="ACC Risk Calculator"]

Date: [date name="variable_1190" default="08/14/2020"]  ECG: [textarea name="variable_1191" default="sample text"]    Location in AHLTA (Clinical Notes, HAIMS, Encounter) dated [date name="variable_1192" default="08/14/2020"]

(HTN)
Stage: [select name="HTN" value="I|II"],[select name="control" value="well controlled|controlled|uncontrolled"]

Treatments:
-Discussed Lifestyle Modifications 
-Medications: see med rec

(HLD) 
Treatments:
-Discussed Lifestyle Modifications 
-Statin: [select name="variable_1185" value="low intensity|mod intensity|high intensity|not indicated because:***"] 
-Medications: see med rec

(DIABETES)
Date: [date name="variable_1180" default="08/14/2020"] HgA1c:[text name="variable_1181" default="sample text"] Goal: [text name="variable_1182" default="sample text"] 
Home BG range: [text name="variable_1183" default="sample text"] Goal(Targets and Frequency): [text name="variable_1184" default="sample text"]

Medications: see med rec 
Insulin: not on insulin 

[select name="variable_1179" value="Yes|No"] ACE-I/ARB
[select name="variable_1178" value="Yes|No"] Aspirin/Antiplatelet Rx
[select name="variable_1177" value="Yes|No"] Annual Urine Microalbumin/Cr:[date name="variable_1" default="today"]  
[select name="variable_1176" value="Yes|No"] Annual Foot Exam/Monofilament test done [date name="variable_1175" default="today"]  
[select name="variable_1174" value="Yes|No"] Biennial Retinal Eye Exam done [date name="variable_1" default="today"]
[select name="variable_1173" value="Yes|No"] Diabetes education class done [date name="variable_1" default="today"]
[select name="variable_1172" value="Yes|No"] Pneumovax given, due again at age 65 [date name="variable_1" default="today"]
[select name="variable_1171" value="Yes|No"] Influenza Vaccination [date name="variable_1" default="today"]
[select name="variable_1170" value="Yes|No"] Hep B Series complete [date name="variable_1" default="today"] 
 
COMANAGING TEAM/CONSULTANTS: [checklist name="variable_1169" value="Endocrinology|Cardiology"]

New Referrals: [text name="variable_1168" default="sample text"]
FOLLOW-UP PLAN: [text name="variable_1167" default="sample text"]
[/conditional]

[conditional field="diagnoses" condition="(diagnoses).is('Pulmonary Disease')"]
Pulmonary Disease Care Plan
 
DIAGNOSIS
ASTHMA - [select name="variable_654" value="Intermittent|Mild Persistent|Moderate Persistent|Severe Persistent"]

Asthma Control Test
Date: [date name="variable_1162" default="08/14/2020"] Score:[text name="variable_1163" default="sample text"]
Date: [date name="variable_1161" default="08/14/2020"] Score:[text name="variable_1164" default="sample text"] 
Date: [date name="variable_1160" default="08/14/2020"] Score:[text name="variable_1165" default="sample text"]

COPD - [select name="variable_654" value="Mild|Moderate|Severe|Very Severe"]
[comment memo="use MMRC dyspnea scale and FEV1"]

Date:[date name="variable_1157" default="08/14/2020"] CAT: [text name="variable_1158" default=""]
Date: [date name="variable_1156" default="08/14/2020"] MMRC: [text name="variable_1159" default=""]
 
Basis for Diagnosis: [text name="variable_1154" default="sample text"]
 
PRECIPITATING FACTORS: 
Prodrome: [textarea name="variable_1153" default="sample text"]
Rapidity of onset: [textarea name="variable_1152" default="sample text"]
Durations: [textarea name="variable_1151" default="sample text"]
Frequency: [textarea name="variable_1150" default="sample text"]
Usual pattern and management: [textarea name="variable_1149" default="sample text"]
 
IMPACT OF DISEASE: [textarea name="variable_1148" default="sample text"]

GOALS:  Maximize symptom control, BMI <30, Avoid tobacco exposure/use, Eliminate trigger exposure

ACTIONABLE DATA:
Date: [date name="variable_1147" default="08/14/2020"] Spirometry completed (Annually for Asthma, baseline for COPD)
Date: [date name="variable_1146" default="08/14/2020"] Pneumococcal Immunization
Date: [date name="variable_1145" default="08/14/2020"] Annual Influenza Immunization
Date: [date name="variable_1144" default="08/14/2020"] Annual Asthma Action Plan provided to patient
[select name="variable_132" value="Yes|No"] Smoking or Smoke/Trigger Exposure
[select name="variable_192" value="Yes|No"] Asthma Long-term controller medication indicated, see med rec
 
CO-MANAGING TEAM/CONSULTANTS: [select name="variable_142" value="Pulmonology|None"]

PATIENT GOALS FOR NEXT APPT: [textarea name="variable_1141" default="sample text"]
TIME FRAME FOR FOLLOW-UP: [text name="variable_1140" default="sample text"]
[/conditional]

[conditional field="diagnoses" condition="(diagnoses).is('Cardiovascular Disorder')"]
Cardiovascular Disorders Care Plan 

DIAGNOSIS: 
[checklist name="CVdisorder" value="Coronary Artery Disease|Cerebral Vascular Disease|Peripheral Vascular Disease|Atrial Fibrillation or other Dysrhythmia|Heart Failure|Valvular Disorder"]  

GOALS:  Modifiable risk factor targets  
BP target <[text name="variable_1139" default="sample text"]
LDL<100 (<70 if high risk)
BMI 20-25
Heart Failure: Minimize symptoms, Maximize functional capacity


ACTIONABLE DATA:
     [select name="variable_1138" value="Yes|No"]  BP at goal? 
     [select name="variable_1137" value="Yes|No"]  BMI at goal?
     [select name="variable_1136" value="Yes|No"]  Tobacco Use
     [select name="variable_1135" value="Yes|No"]  Beta Blocker (post MI or LVEF<40%)
     [select name="variable_1134" value="Yes|No"]  Aspirin

    Pneumococcal Immunization: [select name="variable_1" value="Given|not given"] Date: [date name="variable_1133" default="today"]

     (Heart Failure Only)
     Heart Failure: Minimize symptoms, Maximize functional capacity
     NYHA Class [select name="variable_161" value="I|II|III|IV"] ACC/AHA Stage: [select name="variable_3654" value="A|B|C|D"]
     ACE-I: [select name="variable_1132" value="Yes|No"] 
     Date: [date name="variable_1" default="today"]  Echo LVEF: [textarea name="variable_1131" default="sample text"]
 
     (Afib Only)
     [select name="variable_1130" value="Yes|No"] Rate Controlled (resting HR<110)
     [date name="variable_1123" default="08/17/2020"] CHA2DS2-VASc Score: [text name="variable_cvs" default=""]
     [date name="variable_1124" default="08/17/2020"] HAS-BLED Score: [text name="variable_hbs" default=""]
     Anticoagulation/antiplatelet therapy indicated: [select name="variable_1125" value="Yes|No"]        
     Date started: [date name="variable_1126" default="today"] Anticoagulation/antiplatelet therapy education given
   
COMANAGING TEAM/CONSULTANTS:
[checklist name="variable_1129" value="Cardiology|Neurology|Vascular|Surgery|Nutrition|Pharmacy"]
 
PATIENT INTERNT INTERIM GOALS: [text name="variable_1127" default="sample text"]

FOLLOW-UP PLAN: [text name="variable_1128" default="sample text"]
[/conditional]