Nurse Template

Comprehensive Chronic Care Management (CCM) Notes

A professional Nurse template for healthcare professionals.

About this template

The Comprehensive Chronic Care Management (CCM) Notes template is an essential tool for nurses and healthcare professionals involved in managing patients with multiple chronic conditions. This template facilitates detailed documentation of patient information, chronic and other medical conditions, social needs, and care plans. It supports effective care coordination, medication management, and preventive care strategies. By using this template, clinicians can ensure comprehensive care management, improve patient outcomes, and streamline billing processes with accurate time documentation and appropriate billing codes. Ideal for chronic care management programs, this template enhances patient-centered care delivery.

Preview 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 has stage 2 hypertension with a blood pressure consistently above 140/90 mmHg. Clinical indicators include elevated systolic and diastolic readings. - Management plan includes Lisinopril 20 mg daily, 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

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.)

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