assignment 2

Date:

Client Complexity:

Comfort Assessment

Episodic (Acute Condition)

Multiple/Chronic/Controlled Disease

Multiple/Chronic/Uncontrolled Disease

Single/Chronic/Controlled Disease

Single/Chronic/Uncontrolled Disease

Wellness Screening/HPDP

Immunizations

Type of Visit:

Acute/Episodic Care Other

Chronic Illness Management Visit Postpartum Visit

DOT Physical Pre- Employment Physical

Family Planning Visit Prenatal Visit

Health Maintenance Office Visit School Physical

Immunizations STD/STI Visit

IUD Placement/Check Well Child Exam

Menopause Counseling Women’s Well Visit

New OB Visit

CC:

Initials:

Diagnostics: Cardiopulmonary Laboratory Radiology Screening Tools Other

Age:

Gender: M / F

Procedures and Skills:

Ethnicity:

Medications:

Minutes:

Student Level of Function:

100 75 50 25

Education:

Type of Site:

Therapeutics:

Follow up:

Referrals:

Physical Exam: Cardiac Constitutional/VS Derm Development Endocrine GI Genitalia GU Gyne HEENT

Lymph/Immuno Med Rec Musculoskeletal Neuro OB Other Pain Psych Respiratory

ICD- 10

CPT

Comments