Health Risk Assessment Progress Note

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Health Risk Assessment Progress te ame: DOB: Age: HC: Date: RK AMT UBJCT Y f yes, then: Comments: Has patient been to the R in the past 6 months? Has patient been admitted in the past 12 months? Has patient
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Health Risk Assessment Progress te ame: DOB: Age: HC: Date: RK AMT UBJCT Y f yes, then: Comments: Has patient been to the R in the past 6 months? Has patient been admitted in the past 12 months? Has patient been in a skilled nursing facility in the past 12 months? Has patient been receiving Home Health Care (PT, OT, urse)? s patient currently receiving Hospice services? Does patient have or use durable medical equipment at home? Does patient require any type of medical supplies? Does the patient currently see any specialists? Does the patient live alone? Does the patient have help at home? Has the patient fallen in the past 6 months? Does the patient have any skin breakdown? s patient currently on dialysis? s patient hearing impaired? Are there safety issues at home? s the patient currently being treated by a Behavioral Health Care Provider? s the patient sexually active? here? hat agency? hat agency? hat equipment? hat upplies? hat pecialists? xplain: Location & severity? here? Describe: ho? Does the patient have any of the following conditions (specify Dx below)? Renal Disease CHF Vision Problems Transplant Back Problems Diabetes eizures Other? f so, describe: Cancer HV/AD G Problems Chronic Pain Lung Problems (COPD, Asthma) udden eight Change Does the patient have any of the following behavioral health conditions (specify Dx below)? Anxiety Drug Abuse Attention-Deficit Hyperactivity Disorder Depression moking uicidal ideation Alcohol Abuse Dementia Other (Describe): Past Family Medical and Personal urgical History: Medication Review tatus Reviewed and documented list of current medications, dosage, and last refill date? (Must Attach Meds List) Drug Allergies or ensitivities? known allergies Comments/ClinicalRecommendations Changes? Advance Directive: Discussed igned Advance Directive/HealthCare Power of Attorney Patient ame: DOB: HC # Last, First M FUCTOAL AMT ACTVTY COR COMMT FDG 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent BATHG 5 = independent (or in shower) GROOMG 0 = needs help with personal care 5 = independent face/hair/teeth/shaving DRG 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) BOL 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent BLADDR 0 = incontinent (or catheterized and unable to manage alone) 5 = occasional accident 10 = continent TOLT U 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping) TRAFR (BD TO CHAR AD BACK) 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent MOBLTY (O LVL URFAC) 0 = immobile or 50 yards 5 = wheelchair independent, including corners, 50 yards 10 = walks with help of one person (verbal or physical), 50 yards 15 = independent (but may use aid; for example, stick) 50 yards TAR 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent TOTAL FUCTOAL COR (0 100): PA CAL (circle the indicator that best describes pain level from any one of the cale types below ) umerical cale Verbal cale Pain Mild Pain Moderate Pain evere Pain orst Possible Activity cale Pain Can Be gnored nterferes with Tasks nterferes with Concentration nterferes with Basic eeds Bedrest Required 2 Patient ame: DOB: HC # Last, First M Depression creening Tool PHQ 9: n the past 2 weeks, how often have you been bothered by: Over the last two weeks, how often have you been bothered by any of the following? t at all (=0) everal days (=1) More than half the days (=2) early everyday (=3) 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or over-eating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you been moving a lot more than usual. 9. Thoughts that you are better off dead, or hurting yourself in some way Column Totals: Total core: f you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? 10. t difficult at all omewhat difficult Very difficult xtremely difficult OFFC: Using the Total core above, refer to PHQ-9 core Table and Guidelines and apply appropriate code: PHQ-9 Diagnosis code: 3 Patient ame: DOB: HC # Last, First M Health Maintenance Preventive Care Completed Date of ervice Pneumonia Vaccine Unk Flu Vaccine Unk A1c Testing value: GRF, estimated (serum creatinine) result: Coding Chronic Kidney Disease tages: _tage 4 (585.4): 2 egfr at least 3mos apart; _tage 5/Renal failure (585.5): egfr 15 / dialysis _tage 6/RD (585.6): _V45.11 Dialysis tatus s patient on dialysis? Unk Retinal xam _ non-proliferative retinopathy (362.01) _ proliferative retinopathy (362.02) _ vitreous hemorrhage (379.23) Unk Unk Unk Glaucoma Testing Unk Any fractures in the last 12 months? f yes, have you been dx with Osteoporosis? f yes, is the patient on treatment? Unk Unk Unk Colon Cancer creening - f yes, indicate type of screening test: FOBT igmoidoscopy Colonoscopy Provider ame: Mammogram creening - f yes: Provider ame: Unk Unk History of Mastectomy - f yes: te Provider ame: Right Left Bilateral Unk Did you get any lab work done in the last 6 12 months? Did the PCP review the lab results with you within 2 weeks of getting the results? Assessment of Current Conditions KY: = ew = xisting = table = mproving = orsening 4 Patient ame: DOB: HC # Last, First M PHYCAL XAMATO Does the patient appear well nourished and not in distress? Describe: eight: Height: Calculated BM: Pulse: /min Resp: /min Temp: Vitals: BP / mmhg Repeated BP / mmhg (Repeat after 15 minutes if yst 140 and/or Dias is 90) ystem Findings rmal HT ( lesions-symmetrical; PRRLA, conjunctivae & sclerae clear; Vision grossly norma; Canals clear, TM s normal, hearing grossly normal; Passages clear, MM pink; no masses, no septal deviation, thyroid not enlarged, etc) (Assess visual changes, movement of ocular muscles, etc) Vision Cardiovascular ystem (Look for Heart sounds, murmurs, pacemakers, regular rate and rhythm, normal 1, 2, etc) Respiratory ystem (valuate breath sounds, presence/absence of ronchi and crepts, tracheostomy, etc) Abdomen/ Pelvis (valuate for any swellings, guarding, tenderness, enlarged liver/spleen, lymph nodes, etc) Breast (female only) (valuate for any swellings, tenderness, lymph nodes, etc) Musculoskeletal (valuate for any pain, swellings, joint tenderness, range of movement, etc; cyanosis, clubbing or edema) (valuate gait, speech, muscle strength, reflexes, etc. n focal, C -X L) eurological (valuate for ulcers, pigmentation, swellings, etc) kin (valuate for position/temperature senses, fine touch, decreased senses in extremities, etc) ensory exam Other Findings: Health ducation: Referrals: ext F/U Appt: Print Provider ame and Credentials: Provider ignature and Credentials: Date: 5
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