Chronic Condition Management
Documentation
The patient is reporting the following symptoms:
- No symptoms reported
- Leg edema
- Weakness
- Angina
- Orthostasis
- Dyspnea on exertion
- Paroxysmal nocturnal dyspnea
- Fatigue
- Shortness of breath
- Persistent cough
- Ascites
- Difficulty concentrating
- Chest pain
- Other (please specify)
Note the status of reported symptoms: stable, worsening, unstable, unable to assess
Patient's disposition:
- Patient remained at home without urgent escalation — provider informed
- NCC informed of acute symptoms
- NCC informed of recommendation for urgent care/activation of community paramedicine
- 911 contacted (life threatening signs and symptoms
- Other (please specify)
Interventions:
- Instructed patient/caregiver on importance of monitoring daily weights to prevent symptom exacerbation
- Reviewed the need to report a weight gain of greater than 2lbs in one day or 5lbs in one week to the appropriate provider
- Instructed patient/caregiver to perform daily weights in the morning using the same scale, after urinating and before eating or drinking
- Instructed patient/caregiver to record daily weights in log book
- Other (please specify)
Weight assessment: record patient's reported weight and weight in the past 7 days (range) to assess:
- No change
- Weight gain of > 2 lbs in one day or 5 lbs in one week
- Weight gain of < 2 lbs in one day or 5 lbs in one week
- Weight loss < 2 lbs in one day or 5 lbs in one week
- Weight loss > 2 lbs in one day or 5 lbs in one week
Heart failure medication regimen:
- ACE inhibitor, ARB, ARNI
- Beta-blocker
- Aldosterone antagonist
- Standing diuretic
- PRN diuretic / water pill
- Digoxin
- Other (please specify)
Confirm patient has adequate medication supply and 90-day refills
- If not, are they willing to switch to 90-day refills?
Coordinate with prescribing MD - In agreement for home delivery?
Inquire with listed pharmacy if this is an option
The patient is reporting the following symptoms:
- No symptoms reported
- Shortness of breath with exertion
- Shortness of breath at rest
- Wheezing
- Chest tightness
- Increased mucus production
- Cough
- Cyanosis
- Fatigue
- Somnolence
- Unintentional weight loss
- Night sweats
- Fever and chills
- Other (please specify)
Note the status of reported symptoms: stable, improving, worsening (consult NCC), unable to assess
Escalated to NCC?Yes/No
Access to COPD medications:
- Patient has all prescribed medications and reports no difficulty with obtaining refills
- Patient does have all prescribed medications but reports concerns about obtaining refills
- Patient does not have all prescribed medications
Barriers to obtaining COPD medications:
- Patient reports difficulty with affording medications
- Patient reports difficulty with obtaining new prescriptions from provider
- Patient report difficulty with physically obtaining medications from pharmacy
- Other (please specify)
Intervention relating to COPD medications:
- Informed NCC of SW referral to address financial/physical barriers to obtaining medications
- Informed prescribing provider regarding need for new prescriptions (advocate for 90-day supply)
- Requested care coordinator assistance with scheduling appointment with prescribing provider
- Contacted pharmacy to confirm active prescriptions/refills (opt for home delivery)
- Contacted pharmacy to arrange home delivery of medications
- Other (please specify)
Current medication regimen:
- Metered Dose Inhaler (MDI) with spacer
- Dry powder inhaler (DPI)
- Respimat inhaler
- Nebulizer treatments
- PO medications
- Rescue Pack
- Steroid treatment
- Antibiotic
Confirm patient has adequate medication supply and 90-day refills
- If not, are they willing to switch to 90-day refills?
Coordinate with prescribing MD - In agreement for home delivery?
Inquire with listed pharmacy if this is an option
The patient is reporting the following symptoms:
Hypoglycemia symptoms:
- No symptoms reported
- Confusion
- Dizziness
- Headaches
- Hunger
- Mood changes
- Pallor
- Seizures
- Sleepiness
- Speech difficulty
- Sweats
- Tremors
- Other (please specify)
Hyperglycemia symptoms:
- No symptoms reported
- Confusion
- Dizziness
- Headaches
- Hunger\thirst
- Mood changes
- Nervousness\anxiety
- Pallor
- Seizures
- Sleepiness
- Speech difficulty
- Sweats
- Tremors
- Other (please specify)
Note the status of reported symptoms: stable, improving, worsening (consult NCC), unable to assess
Record blood glucose reading today and in the last 3 days. Inform NCC if reading is less than 60 mg/dl or more than 250 mg/dl.
Escalated to NCC? Yes/No
Insulin regimen: (name of med)
- Dose schedule
- Pre-breakfast
- Pre-lunch
- Pre-dinner
- Bedtime
- Given by
- Patient
- Adult caretaker
- Friend
- Grandparent
- Nursing attendant
- Parent
- Relative/sibling
- Significant other
Confirm patient has adequate medication supply and 90-day refills
- If not, are they willing to switch to 90-day refills?
Coordinate with prescribing MD - In agreement for home delivery?
Inquire with listed pharmacy if this is an option
- Refer to clinical providers (specialist, clinical pharmacist, primary care)
- Schedule in-person or virtual visit (if possible)
- Will you be able to attend or get this appointment?