Care Management Chart Review Tool
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1
2Care Management Chart Review Tool
DEMOGRAPHIC
Name: ____________________________ DOB: ______________Gender: ________Insurance: _______
PCP Name: _________________________ Phone Number:__________________________
Care Manager: ______________________Phone Number:__________________________
Health team/community supports:
Role (Mental Health provider, health coach, SASH, etc):
_____________________________________
____________________________________________
_____________________________________
____________________________________________
_____________________________________
____________________________________________
_____________________________________
____________________________________________
_____________________________________
____________________________________________
_____________________________________
____________________________________________
PRIMARY DX: _______________________________________________________________
OTHER KEY DIAGNOSES (include Active and Historical): ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
MEDICAL NEIGHBORHOOD
Two or more admissions to the hospital in the past 6 month?
YES
NO
Three or more Emergency room visits in the past 6 months?
YES
NO
Has not been to PCP in past year?
YES
NO
No documented Goals of Care conversation or Advanced Directive on file?
YES
NO
COMMENTS:
MEDICAL STATUS/HEALTH TRAJECTORY
Uses 5 or more medications?
YES
NO
Greater than 3 chronic health conditions?
YES
NO
Requires assistance with ADLs (Activities of Daily Living)?
YES
NO
COMMENTS:
V. 11.20.2015
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Parent category: Medical