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Registered Nurse
20-25 minutes

Detailed Notes on Chronic Care Management (CCM)

The Comprehensive Chronic Care Management (CCM) Notes template by s10.ai is a vital resource for nurses and healthcare professionals dedicated to managing patients with multiple chronic conditions. This template enables thorough documentation of patient data, chronic illnesses, social determinants, and individualized care plans. It enhances care coordination, medication management, and preventive care strategies. By adopting this template, clinicians can ensure holistic care management, boost patient outcomes, and optimize billing processes with precise time tracking and correct billing codes. Perfect for chronic care management programs, this template elevates patient-centered care delivery.

3,078 uses
4.5/5.0
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Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

Reporting Month/Year: [Enter Month/Year]
Patient Information
Full Name: [Enter Patient Name]
Date of Birth (DOB): [MM/DD/YYYY]
Medical Record (MR) : [Enter MR]
Type of Residence: [Specify whether Home, Group Home, Other]
Chronic Conditions (2 or more required for eligibility)
- [Condition Name] (ICD-10: [Code]) – [Provide a brief description of the condition, including severity, stage (if applicable), and relevant clinical indicators.]
- [Describe the management plan, including medications, non-pharmacologic interventions, and monitoring strategies.]
- [Condition Name] (ICD-10: [Code]) – [Provide a brief description of the condition, including severity, stage (if applicable), and relevant clinical indicators.]
- [Describe the management plan, including medications, non-pharmacologic interventions, and monitoring strategies.]
- [Optional Additional Condition] (ICD-10: [Code]) – [Provide a brief description of the condition, including severity, stage (if applicable), and relevant clinical indicators.]
- [Describe the management plan, including medications, non-pharmacologic interventions, and monitoring strategies.]
Other Medical Conditions
- [Condition Name] – [Provide a brief description of the condition and its impact on the patient's overall health.]
- [Describe management strategy, including medications, lifestyle modifications, and any necessary referrals or monitoring requirements.]
- [Condition Name] – [Provide a brief description of the condition and its impact on the patient's overall health.]
- [Describe management strategy, including medications, lifestyle modifications, and any necessary referrals or monitoring requirements.]
Other Needs (Social and Access to Care)
- Transportation Needs: [Specify assistance required, if any, such as reliance on family, community services, or medical transport.]
- Social Support System: [Describe the patient’s support network, including family, caregivers, or community resources.]
- Nutritional Needs: [Outline dietary restrictions, challenges, meal planning needs, and whether referral to a dietitian is required.]
- Psychosocial and Mental Health Needs: [Discuss cognitive status, mood disorders (e.g., depression, anxiety), and other behavioral health considerations.]
- Functional Limitations: [Describe mobility issues, limitations with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and required assistance.]
Physician or Qualified Health Professional (QHP) Responsible for CCM
Primary Physician/QHP: [Provider Name, Credentials]
Date Initial Plan of Care Developed: [MM/DD/YYYY]
Date Plan of Care Provided to Patient/Caregiver: [MM/DD/YYYY]
Consent Documentation
- Verbal or Written Consent Obtained: Yes or No
- Date of Consent: [MM/DD/YYYY]
- Consent Notes: [Specify any patient concerns regarding CCM services, cost-sharing discussions, or need for additional explanation.]
Care Plan Components
- Assessment of Patient’s Medical, Functional, and Psychosocial Needs: [Provide a detailed overview of medical conditions, functional status, psychosocial challenges, and overall health risks.]
- Preventive Care Needs Addressed: [List any screenings, vaccinations, or preventive services recommended and performed.]
- Medication Reconciliation and Self-Management Plan: [List current medications, dosages, frequency, and any recent medication changes. Include instructions given to the patient on adherence and self-management.]
- Care Coordination and Communication:
- Coordination with [Provider or Specialist] for [Reason]
- Referral to [Community Resource] for [Support Service]
Care Transition Management
- Hospital or Facility Discharges in the Past 30 Days: Yes or No
- Recent Emergency Department Visits: Yes or No
- Follow-up Actions Required: [Specify follow-up care, appointments, referrals, or monitoring plans.]
- Continuity of Care Documents Shared: Yes or No
Chronic Care Management Activities and Time Documentation
Date: [MM/DD/YYYY]
- Activity: [Describe the activity in detail, such as patient education, medication review, or care coordination efforts.]
- Time Start and Stop: [HH:MM AM/PM - HH:MM AM/PM]
- Total Time: [XX minutes]
- Documentation Reference: [EHR Note, Call Notes, etc.]
- Signature: [Name and Credentials]
Date: [MM/DD/YYYY]
- Activity: [Describe the activity in detail, such as patient education, medication review, or care coordination efforts.]
- Time Start and Stop: [HH:MM AM/PM - HH:MM AM/PM]
- Total Time: [XX minutes]
- Documentation Reference: [EHR Note, Call Notes, etc.]
- Signature: [Name and Credentials]
Date: [MM/DD/YYYY]
- Activity: [Describe the activity in detail, such as patient education, medication review, or care coordination efforts.]
- Time Start and Stop: [HH:MM AM/PM - HH:MM AM/PM]
- Total Time: [XX minutes]
- Documentation Reference: [EHR Note, Call Notes, etc.]
- Signature: [Name and Credentials]
Total CCM Time for Month: [XX minutes]
Billing Codes and Documentation
- 99487 – Complex Chronic Care Management (CCCM), at least 60 minutes of clinical staff time
- 99489 – Additional 30 minutes of CCCM (Enter number of units: [X])
- 99490 – Standard Chronic Care Management (CCM), at least 20 minutes of clinical staff time
- 99439 – Additional 20 minutes of CCM (Up to 2 units)
- 99491 – CCM, at least 30 minutes of physician time
- 99X21 – Additional 30 minutes of physician time
- 99X22 – Principal Care Management (PCM), at least 30 minutes of physician time
Supervising Physician or QHP Signature
[Provider Name, Credentials]
Date: [MM/DD/YYYY]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Reporting Month/Year: November 2024
Patient Information  
Full Name: John Doe  
Date of Birth (DOB): 01/15/1950  
Medical Record (MR) : 123456789  
Type of Residence: Home  
Chronic Conditions (2 or more required for eligibility)  
- Hypertension (ICD-10: I10) – The patient presents with stage 2 hypertension, consistently recording blood pressure readings above 140/90 mmHg. Clinical indicators include elevated systolic and diastolic measurements.  
  - Management plan includes Lisinopril 20 mg daily, a low-sodium diet, regular blood pressure monitoring, and bi-weekly telehealth check-ins.  
- Type 2 Diabetes Mellitus (ICD-10: E11.9) – The patient has poorly controlled diabetes with an HbA1c of 8.5%. Clinical indicators include elevated blood glucose levels and neuropathy.  
  - Management plan includes Metformin 500 mg twice daily, dietary modifications, regular blood glucose monitoring, and monthly endocrinologist consultations.  
Other Medical Conditions  
- Hyperlipidemia – The patient has elevated cholesterol levels impacting cardiovascular health.  
  - Management strategy includes Atorvastatin 10 mg daily, dietary changes, and quarterly lipid panel tests.  
- Osteoarthritis – The patient experiences joint pain and stiffness, affecting mobility.  
  - Management strategy includes physical therapy, NSAIDs as needed, and referral to an orthopedic specialist.  
Other Needs (Social and Access to Care)  
- Transportation Needs: Relies on community services for medical appointments.  
- Social Support System: Supported by family and local senior center resources.  
- Nutritional Needs: Requires low-sodium and low-sugar diet; referred to a dietitian.  
- Psychosocial and Mental Health Needs: Mild depression managed with counseling and support groups.  
- Functional Limitations: Requires assistance with ADLs due to joint pain.  
Physician or Qualified Health Professional (QHP) Responsible for CCM  
Primary Physician/QHP: Dr. Emily Carter, MD  
Date Initial Plan of Care Developed: 10/01/2024  
Date Plan of Care Provided to Patient/Caregiver: 10/05/2024  
Consent Documentation  
- Verbal or Written Consent Obtained: Yes  
- Date of Consent: 10/01/2024  
- Consent Notes: Patient expressed concerns about medication costs, discussed potential financial assistance.  
Care Plan Components  
- Assessment of Patient’s Medical, Functional, and Psychosocial Needs: Comprehensive review of chronic conditions, mobility issues, and mental health status.  
- Preventive Care Needs Addressed: Annual flu vaccination and diabetic foot exam performed.  
- Medication Reconciliation and Self-Management Plan: Current medications reviewed, patient instructed on adherence and lifestyle modifications.  
- Care Coordination and Communication:  
  - Coordination with Dr. Smith, Endocrinologist, for diabetes management.  
  - Referral to Senior Center for social support services.  
Care Transition Management  
- Hospital or Facility Discharges in the Past 30 Days: No  
- Recent Emergency Department Visits: No  
- Follow-up Actions Required: Continue regular monitoring and scheduled appointments.  
- Continuity of Care Documents Shared: Yes  
Chronic Care Management Activities and Time Documentation  
Date: 11/01/2024  
- Activity: Medication review and patient education on lifestyle changes.  
- Time Start and Stop: 09:00 AM - 09:30 AM  
- Total Time: 30 minutes  
- Documentation Reference: EHR Note  
- Signature: Nurse Jane Smith, RN  
Date: 11/15/2024  
- Activity: Care coordination with endocrinologist and dietitian.  
- Time Start and Stop: 10:00 AM - 10:45 AM  
- Total Time: 45 minutes  
- Documentation Reference: Call Notes  
- Signature: Nurse Jane Smith, RN  
Date: 11/29/2024  
- Activity: Follow-up on patient’s adherence to care plan and psychosocial support.  
- Time Start and Stop: 11:00 AM - 11:30 AM  
- Total Time: 30 minutes  
- Documentation Reference: EHR Note  
- Signature: Nurse Jane Smith, RN  
Total CCM Time for Month: 105 minutes  
Billing Codes and Documentation  
- 99487 – Complex Chronic Care Management (CCCM), at least 60 minutes of clinical staff time  
- 99489 – Additional 30 minutes of CCCM (Enter number of units: 1)  
- 99490 – Standard Chronic Care Management (CCM), at least 20 minutes of clinical staff time  
- 99439 – Additional 20 minutes of CCM (Up to 2 units)  
- 99491 – CCM, at least 30 minutes of physician time  
- 99X21 – Additional 30 minutes of physician time  
- 99X22 – Principal Care Management (PCM), at least 30 minutes of physician time  
Supervising Physician or QHP Signature  
Dr. Emily Carter, MD  
Date: 11/30/2024
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive Chronic Care Management (CCM) template is designed to streamline patient care documentation, ensuring healthcare providers can efficiently manage patients with multiple chronic conditions. By incorporating high-search healthcare keywords, this template facilitates detailed recording of patient information, chronic and other medical conditions, and social needs, enhancing care coordination and communication. It includes sections for documenting care plan components, care transition management, and chronic care management activities, complete with time tracking and billing codes. This template is an essential tool for clinicians aiming to improve patient outcomes through meticulous care planning and management, encouraging adoption and implementation for optimized clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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Detailed Notes on Chronic Care Management (CCM)