Patient Name MRN Age DOB Ethnicity Immigrant/Refugee Status Patient Goals Current Dx Substance Use: Alcohol Tobacco Marijuana Other Drugs: ___________________________________________ Last HbA1c Last HbA1c Date Range of HbA1c over last year BP at target If BP not at target, last BP Last BP Date Statin: Yes No ASA: Yes No ACE or ARB: Yes No Last BMI Last BMI Date Last PHQ-9 Last PHQ-9 Date Last GAD-7 Last GAD-7 Date Last SU Assessment Last SU Assessment Date Recent ER Visits/Hospitalizations Rx Patient Strengths Patient Stressors/Barriers What is the problem? How will we intervene? Who will do what? When will this happen? Action List:
Patient Name MRN Age DOB Ethnicity Immigrant/Refugee Status Patient Goals Current Dx Substance Use: Alcohol Tobacco Marijuana Other Drugs: ___________________________________________ Last HbA1c Last HbA1c Date Range of HbA1c over last year BP at target If BP not at target, last BP Last BP Date Statin: Yes No ASA: Yes No ACE or ARB: Yes No Last BMI Last BMI Date Last PHQ-9 Last PHQ-9 Date Last GAD-7 Last GAD-7 Date Last SU Assessment Last SU Assessment Date Recent ER Visits/Hospitalizations Rx Patient Strengths Patient Stressors/Barriers Action List: What is the problem? How will we intervene? Who will do what? When will this happen?
6_HandoutSystematicCaseReviewTemplate.docx