Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Service:
Chronic Condition(s): (List the relevant chronic conditions the patient is being managed for)
Summary of Current Status
Briefly describe the patient’s current health status related to their chronic condition(s).
Include recent changes in symptoms, medication adherence, or functional status.
Care Plan Review
Summarize the current care plan for the patient’s chronic condition(s).
Mention any medications, self-management strategies, or referrals to specialists included in the plan.
Services Provided
Document the specific Chronic Care Management services provided during this encounter. This may include:
Reviewing vital signs, labs, and other recent test results.
Assessing medication adherence and potential side effects.
Educating the patient on their condition and self-management strategies.
Coordinating care with other healthcare providers involved in the patient’s care.
Developing a transition plan following a hospitalization or emergency department visit (if applicable).
Addressing any psychosocial concerns impacting the patient’s ability to manage their condition.
Patient Education
Briefly mention any specific patient education initiatives undertaken during this encounter.
This could include information about:
Disease management
Medication use
Healthy lifestyle habits
Symptom recognition and management
Care Plan Updates
Document any adjustments made to the patient’s care plan based on the assessment and services provided.
This may include changes in medications, referrals to specialists, or adjustments to self-management strategies.
Coordination of Care
If there was communication or collaboration with other healthcare providers involved in the patient’s care, briefly document it here.
This may involve sending a summary of the visit or discussing any adjustments to the treatment plan.
Next Steps
Outline the next steps in the patient’s chronic care management program.
This may include scheduling follow-up appointments, renewing referrals, or monitoring specific health parameters.
Important Note:
The specific content of a CCM note may vary depending on your facility’s Chronic Care Management program and the patient’s individual needs.
Always refer to your local and national guidelines for billing and documenting Chronic Care Management services.