goals and timing, new intervention and self-care activities are discussed and agreed to by the patient. The new/changed activities are scheduled and target dates agreed upon. The allied health care provider updates the clinical notes and the care plan with the assessment details, and any changes to the management plan including new advice to the patient. The date of next visit is also determined. Table X.4.2.1.1.2-1: Allied Health Professionals/Specialists Encounters Activities and – Outcomes Provider / Encounter Activities Outcomes Communications Allied Health Provider Diabetic Educator Review referral/patient Develop/update education plan New/updated education progress plan to patient Update clinical assess learning needs and Summary care plan and Generate progress notes strategy progress note shared with primary care provider and discuss and finalize care providers, education plan Dietitian/Nutritionist Review referral/patient Develop/update diet plan New/updated care plan to progress patient Weight assessment; Exercise plan Assess diet management Summary care plan and Diet management plan; needs and strategies progress note shared with Referral to educator and exercise primary care provider and Discuss and finalize diet therapy if necessary other care providers, e.g., management plan Update clinical notes diabetic educator, Generate progress notes exercise physiologist, etc. Exercise Review referral/patient Develop/update exercise plan: New/updated exercise Physiologist progress plan to patient Weight assessment; exercise plan Assess exercise/activity Summary care plan and Update clinical notes needs and strategies progress note shared with Generate progress primary care provider and Discuss and finalize other care providers, e.g., exercise plan diabetic educator, dietitian, etc.
goals and timing, new intervention and self-care activities are discussed and agreed to by the patient. The new/changed activities are scheduled and target dates agreed upon. The allied health care provider updates the clinical notes and the care plan with the assessment details, and any changes to the management plan including new advice to the patient. The date of next visit is also determined. Table X.4.2.1.1.2-1: Allied Health Professionals/Specialists Encounters – Activities and Outcomes Provider / Allied Health Provider Encounter Activities Outcomes Communications Diabetic Educator Review referral/patient progress assess learning needs and strategy discuss and finalize education plan Develop/update education plan Update clinical Generate progress notes New/updated education plan to patient Summary care plan and progress note shared with primary care provider and care providers, Dietitian/Nutritionist Review referral/patient progress Assess diet management needs and strategies Discuss and finalize diet management plan Develop/update diet plan Weight assessment; Exercise plan Diet management plan; Referral to educator and exercise therapy if necessary Update clinical notes Generate progress notes New/updated care plan to patient Summary care plan and progress note shared with primary care provider and other care providers, e.g., diabetic educator, exercise physiologist, etc. Exercise Physiologist Review referral/patient progress Assess exercise/activity needs and strategies Discuss and finalize exercise plan Develop/update exercise plan: Weight assessment; exercise plan Update clinical notes Generate progress New/updated exercise plan to patient Summary care plan and progress note shared with primary care provider and other care providers, e.g., diabetic educator, dietitian, etc.
IHE_PCC_Suppl_DCP_Rev1_0_PC_2016-05_xx_ej.docx