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This Patient Registry is intended to provide physicians the opportunity to start managing their patient population.
The guidelines described for each condition are of descriptive nature and for illustrative purposes only.
It is the physician's choice to track one or more conditions.
The Patient Centered Care Consultant will gather the guidelines you would like to use for the chosen condition and deliv
Once this tool is implemented and conditions tracked the Patient Centered Care Consultant will help identify areas of im
Please contact your Patient"Centered Care Consultant
Take Action Identify values outside parameters discuss if campaign to improve outcomes is needed. Consider holding specific clinic
Approach #olistic$ while condition focused.
Value #elp organi%e physicians$ to sort patients' conditions to identify gaps. These gaps may or may not mimic &nthem reports
Critical Condition Element Critical Condition Element Critical Condition Element
Diabetes Abnormal when: CHF Abnormal when: CAD A
P ()*+!,+ P ()*+!,+ ()-+!,+over + P ()
/asting lipid profile date () year /asting lipid profile date () year /asting lipid profile date ()
/asting lipid profile " 232 .() yr /asting lipid profile " 232 .() yr /asting lipid profile " 232 .(
4tatin 1o 4tatin 1o 4tatin 1o
0I (5*., 0I (5*., 0I (50edication use counsel 1o 0edication use counsel 1o 0edication use counsel 1o
8/ documented 1o
1o 8/9*+: &C8I!&R 1o
1o 8/9*+: blocker 1o &spirin 1o
&IC ( ; &spirin 1o
&IC date ( months
Increased
3yneaorthopnea Increased
Retinal 86am 3ate ( ) year 8dema Increased
( ) year
?rine 0icroalbumin date () year
?rine 0icroalbumin =alue ( @+mg!5*hr
4erum Creatinine 3ate () year
9 5 < eA/R9+>
8R #ospitali%ation 7es 8R #ospitali%ation 7es 8R #ospitali%ation 7e
&C8!&R if P and!or urinemicroalb abnl
&spirinB!or Clopidigrel
3aily Deight! Change(E*lbs over Ftarget wtF
/oot 2esion!1europathy 86am3ate
4erum Creatinine$ nephrologistreferral
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Patient name Gender DOB Clinician BP Statin BMI
!astin" lipid
pro#ile date
Medication
$se Counsel
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AIC AIC date
Aspirinand /orClopi"rel%i#DM & CVD
isk'
etinal E(am
Date
!oot )esion/*europath+ E(am
Date
Urine
Microalbum
in Value
$rineMicroal,umin
date
SerumCreatinine
Date
SerumCreatinine*ephrolo"istre#erral -.
%eG!-0'
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To,acco $se
E/
1ospitali2ation
Dietar+
Counsel
E(ercise
Counsel
DM Sel# M"mteducation3
monitor BG
!lu Vaccine
Date 4earl+
PneumoVaccine%consider
repeat i# 56'
1ep BVaccine
series
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atient name Gender DOB Clinician To,acco usePeak !lo7Measurement
BaselineSpirometr+
AsthmaAction Plan
1ome/En8ironmentalcounsel
Medicationusecounsel
E/1ospitali2ation
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u9 +earl+Pneumo8a(9once9%consider repeat i#56'
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Gender DOB Clinician Date
atient
ame
Baseline
Spirometr+
Peak !lo7
Measurement
O(+"ensaturation
:
O(+"en
Dependent
Medication
use counsel
Compliance7ith (
o(+"en
E(er
coun
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To,acco $se
E /ospitali2a
tion
!lu Vaccine
Date
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atient *ame Gender DOB Clinician Statin BMI AspirinBloodPressure
!astin")ipidPro#ile
Medication$se Counsel
E/1ospitali2ation
DieCo
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o,accose
E(erciseCounsel
!luVaccine
4earl+
Pneumo8a(%Considerrepeat i# 56'
TotalCholesterol
1ep BImmuni2ationSeries
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atient *ame Gender DOB Clinician Blood Pressure Statin BMI
!astin")ipidPro#ile
Medication$seCounsel
E!Documented
E! -;ACE/
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Aspirin Edema Dietar+ Counsel To,acco $se!-;0:,locker
TotalCholesterol
Dail+7ei"ht/chan"e5;l,s o8er
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lcohol use 5 .er da+
E(erciseCounsel
!luVaccine
4earl+
Pneumo8a(%considerrepeat i#56'
1ep BImmuni2ationSeries
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atient name Gender DOB Clinician Contact Date B1 e#erralP1=.Score
P1=>Score %Must
,e completedi# P1=. ispositi8e'
GAD ?Score
B1Pro8ider
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1
escreenate
A$DIT @Su,stance
$se ScreenScore
Su,stance
$see#erral Su,stance $se!ollo7 $p Date Su,stance $seescreen Date Medication $seCounsel Co@Mor,idCondition
On Medical
Conditione"istr+
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Patient *ame Gender DOB Clinician
Tar"etBloodPressure
CurrentBloodPressure
Presenceo# risk#actors
)a, DataSerum&
SerumCreatinine%eG!'
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1,Ac CBC BMICholesteroland )D)
$rine/al,umincreatinine
Medication $seCounsel
E/1ospitali2ation
DietCounsel
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To,acco$se
E(erciseCounsel
!luVaccine 4earl+
Pneumo8a(%Considerrepeat i#56'
1ep BImmuni2ationSeries
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References
&sthma "
COP3 "
Aold COP3 Retrieved from httpG!!www.goldcopd.org!uploads!users!files!AO23H&t&AlanceH5+)@H/eb5+.pdf
ReferenceGhttpG!!www.ndei.org!&3&"5+)*"guidelines"diabetes"diagnosis"&)C"testing.asp6
httpG!!circ.ahaournals.org!content!)5)!5*!5,*.full.pdf
ehavioral #ealth "
Debsite instructional manual on P#J and A&3 screeners for 3epression and &n6iety " link also on our Provider Toolk
Provides a variety of screening tools available " depression an6iety drug!alcohol use bipolar suicide risk and trauma
#ealth Team Dorks &sthma Care /lowsheet. Retrieved from httpG!!healthteamworks"media.precis-.com!)*+f,,d-5)@fd+ece+@)*Ke5e*)e
#ealth Team Dorks &sthma Care /lowsheet. Retrieved from httpG!!healthteamworks"media.precis-.com!c@@-;@*dbc+b)ded;*5)cfc));-+
C&3 " httpsG!!collaborate.wellpoint.com!sites!PCPCHTeam!Transformation:5+4trategy!PC5:5+Change:5+Package:5+Package!C&3:5+Provider:5+Resources!Cardiovascular:5+Care:5+/low:5+sheet.pdf
httpG!!www.phLscreeners.com!overview.asp6M4creenerE+@HA&3";
httpG!!www.integration.samhsa.gov!clinical"practice!screening"tools
N/or depression
NPatient #ealth Juestionnaire or P#J. & score of @ or higher on the P#J"5 suggests the need for additional would then administer Luestions @", of the P#J",. The P#J", rates the level of depressive symptoms as 0i0oderately 4evere or 4evere.
-", is 0inimal symptoms " offer support educate to call if worse return in one month)+")* is 0inor depression 3ysthymia 0aor 3epression mild " support watchful wating$ anti"depressant and)-"), is 0aor depression moderately severe " antidepressant and!or psychotherapy5+ or greater is 0aor depression severe " antidepressant and psychotherapy
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httpG!!www.nchealthliteracy.org!hfselfmanage.html
httpG!!www.cardiology.org!recentpapers!susiechfc.pdf
httpG!!circ.ahaournals.org!content!)),!)*!),;;.full.pdf