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- CLIENT:
- SOURCE:
- Memo:
- Timestamp:
- Detail:
- Pro?
- Client?
- Organization: {FACILITY}
- Source data: .....
- Is duplicate? FALSE
-
- INTAKE:
- Text:
- Detail:
- DEMOGRAPHICS:
-
- Name:
- Prefix:
- First:
- Middle:
- Last:
- Suffix:
- Nickname:
- Maiden:
- Previous:
-
- DOB: SYTEM: Age in Years:
- Sex:
- Gender identity:
- Sexual orientation:
- Sexually active:
- Marital status:
- Spouse: {RELATIONSHIP}
-
- Responsible party:
- Is someone else the responsible party?
- if(isResponsiblePartySomeoneElse){
- {RELATIONSHIP}
- }
-
- Emergency contact: {RELATIONSHIP}
-
- PHONE:
-
- Home:
- Mobile:
- Work:
- Memo:
-
- EMAIL:
-
- Personal:
- 1.
- 2.
-
- Work:
- 1.
- 2.
-
- REMINDERS VIA:
- Email:
- Text:
- Phone:
-
- ADDRESS:
-
- Is home same as mailing address?
-
- Home:
- ...
-
- Mailing:
- ...
-
- Has secondary address?
-
- Is home same as mailing address?
-
- Home:
- ...
-
- Mailing:
- ...
- Family:
-
- Mother: {RELATIONSHIP}
- Father: {RELATIONSHIP}
- # siblings:
- Birth order:
- Multiple birth member?
-
- Relationships:
-
- foreach({RELATIONSHIP})
- Citizenships:
- Education:
- Birth place:
- Birth state:
- Birth city:
- Nationality:
- Religious affiliation:
-
- Religious Organization: {FACILITY}
-
- Special diet?
- Category:
- Memo:
-
- Preferred language:
- Other languages:
- English level:
-
- Driver license: [State] [Number...]
-
- Is hispanic?
- Is black/AA?
- Ethnicities:
- Race:
- Specific races:
-
- Is deceased?
- Date/time of death:
- Cause of death:
-
- PHARMACY: [STRING]
- Facility record: {FACILITY}
-
- SSN:
-
- MCN:
- MCN:
- SSN:
- First name:
- Last name:
- DOB:
- Part B primary?
- Hospice?
- Response data:
- Billing address:
- Reason not Part B:
- Memo:
- Medicare Advantage?
- Plan:
-
- MCP: {PRO}
- Has MCP done onboarding visit?
- if(yes)
- MCP onboarding visit date:
- MCP onboarding visit note:
- Is MCP onboarding visit note outside system?
- Reason:
-
- MCP ONBOARDING PRO:
- // if(!has_mcp_done_onboarding_visit) {
- Is MCP onboarding active? // ONLY MAKES SENSE if !onboardingVisit
- Why is MCP onboarding not active? [category]
- Memo:
-
- Next onboarding attempt date/time: [DATE] [TIME]
-
- MCP Onboarding Pro: {PRO}
- Decision to accept/reject assignment?
- At:
-
- (SYSTEM)
- # of MCP onboarding phone calls:
- # of MCP onboarding in-person visits:
-
- Attempts: (SEELCT * FROM interaction WEHRE purpsoe = "mcp_onbaoaridng")
- Date | Pro | Outcome | Memo | Geostamp
-
- Dietitian:
-
- RD: {rdPro}
-
- Eligible for MNT?
- Number of MNT hours left this calendar year: {0.5}
-
- CCM:
-
- Care Manager: {PRO}
-
- Eligible?
- if(not) Reason:
-
- Enrolled?
- Consent method:
- Memo:
- if(not)
- Why not enrolled?
- Memo:
- CCM Chronic Diagnoses:
- 1. {cmReason1}
- 2. {cmReason2}
-
- RM:
-
- RME: {rmePro} // manages equipment
-
- RMM: {rmmPro} // bills time each month
-
- Eligible?
- if(not) Reason:
-
- Enrolled?
- Consent method:
- Memo:
- if(not)
- Why not enrolled?
- Memo:
- Focus areas:
- 1.
- 2.
-
- EQUIPMENT:
-
- Awaiting setup?
- What equipment:
-
- Setup completed?
- What equipment:
-
- Service needed?
- What equipment:
- WEBCAM:
- Has webcam device?
- Device type:
- Patient portal:
- Username:
- Password: if(set) *** else <i>Password not set.</i>
- Currently in meeting?
- if(yes)
- Meeting: {MEETING}
-
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