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Primary Care Physician
20-25 minutes

Chronic Care Management (CCM) Documentation

The Chronic Care Management (CCM) Note template by s10.ai is crafted for family medicine specialists to meticulously document follow-up visits for patients with chronic illnesses. This template enables detailed recording of patient-reported symptoms, physical examination findings, and comprehensive care management plans for conditions like hypertension, diabetes, and kidney disease. It includes sections for discussing medication adherence, recent laboratory results, and specialist referrals. Utilizing this template with s10.ai ensures thorough documentation, thereby enhancing patient care and coordination. Perfect for managing complex cases, this template empowers clinicians to deliver personalized and effective chronic care management.

3,023 uses
4.5/5.0
D
Dr. Jonathan Reed
Template Structure

Organized sections for comprehensive clinical documentation

SUBJECTIVE
[Patient demographics and reason for follow-up]
Objective
[Care Management - Condition 1]
[Reported by patient]
[Symptoms and severity]
[Associated symptoms]
[Condition 2]
[Reported by patient]
[Control and adherence to treatment plan]
[Complications]
[Condition 3]
[Reported by patient]
[Severity]
[Self care]
[Associated symptoms]
Physical Exam
[Physical examination findings or note if not performed due to visit type]
Assessment and Plan
Physical Exam
[Physical examination findings or note if not performed due to visit type]
Assessment / Plan
[Clinical goals and recommendations for each condition]
Discussion Notes
[s10.ai chart review and care management call details]
[Patient's general condition and support system]
[Patient's engagement in treatment plan]
[Recent events (ER visits, falls)]
[Medication adherence and refill status]
[Recent lab results]
[Specialist referrals and follow-ups]
[Upcoming appointments and transportation arrangements]
[Patient education and follow-up instructions]
Sample Clinical Note

Example of completed documentation using this template

SUBJECTIVE  
John Doe, a 67-year-old male, returns for a follow-up appointment for chronic care management. His medical history includes hypertension, type 2 diabetes, and chronic kidney disease.
Objective
Care Management - Hypertension  
Reported by patient: John mentions feeling generally well but occasionally has mild headaches.  
Symptoms and severity: Mild headaches, occurring once or twice weekly.  
Associated symptoms: No dizziness or visual disturbances noted.
Condition 2 - Type 2 Diabetes  
Reported by patient: John indicates he is following his diet and medication regimen.  
Control and adherence to treatment plan: Blood sugar levels are mostly within the target range, with occasional increases.  
Complications: No new complications noted.
Condition 3 - Chronic Kidney Disease  
Reported by patient: John reports no new symptoms.  
Severity: Stable, with no recent changes in kidney function.  
Self care: Complies with fluid and dietary restrictions.  
Associated symptoms: No swelling or fatigue noted.
Physical Exam  
Blood pressure: 130/80 mmHg, Heart rate: 72 bpm, Weight: 85 kg. No physical exam conducted due to the nature of the visit.
Assessment and Plan
Assessment / Plan  
Hypertension: Continue current medication, monitor blood pressure at home, and follow up in 3 months.  
Type 2 Diabetes: Maintain current treatment plan, monitor blood glucose levels, and schedule a follow-up with the endocrinologist.  
Chronic Kidney Disease: Continue dietary restrictions, monitor kidney function tests, and follow up in 6 months.
Discussion Notes  
CCM chart review and care management call details: Reviewed recent lab results and medication adherence.  
Patient's general condition and support system: John is stable and has a supportive family.  
Patient's engagement in treatment plan: Actively engaged and adherent to the treatment plan.  
Recent events (ER visits, falls): No recent ER visits or falls reported.  
Medication adherence and refill status: Adherent to medication regimen, refills up to date.  
Recent lab results: Kidney function stable, HbA1c at 7.0%.  
Specialist referrals and follow-ups: Endocrinologist follow-up scheduled.  
Upcoming appointments and transportation arrangements: Next appointment in 3 months, transportation arranged by family.  
Patient education and follow-up instructions: Educated on the importance of medication adherence and lifestyle modifications. Follow-up instructions provided.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient follow-up visits by integrating high-priority healthcare keywords and structured documentation. It begins with capturing essential patient demographics and the reason for follow-up, ensuring a personalized approach. The Objective section meticulously documents patient-reported symptoms, severity, and adherence to treatment plans across multiple conditions, enhancing care management and patient engagement. The Physical Exam section provides a detailed account of examination findings, crucial for accurate assessment and planning. The Assessment and Plan section outlines clinical goals and tailored recommendations, promoting effective patient outcomes. Discussion Notes offer a thorough review of care management, including CCM chart reviews, medication adherence, and recent lab results, ensuring a holistic view of the patient's health status. This template encourages clinicians to adopt a systematic approach, facilitating improved patient care and streamlined clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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Chronic Care Management (CCM) Documentation