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Complex Care Plan

This is a form for recording a complex care plan - billing codes 14030 14031 and 14033. It is a standalone form ie it doesn't require an image file to be uploaded with it. Contributed by Shelter Lee, Crossroads Family Practice, Chilliwack, BC.

ComplexCareForm.html — HTML, 11Kb

File contents

<html>
<title>Complex Care Plan</title>
<head>

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</head>

<body>
<form method="post" action="" name="ComplexCareForm">

<p class="title">
	Complex Care Plan
</p>
<div name="demographics">
<table width="100%">
	<tr>
		<td class="heading1"  colspan="4">Patient Demographics:</td>
	</tr>
	<tr>
		<td class="heading2">Patient name</td>
		<td class="normaltext" colspan="3"><input class="formtext" name="Patient_Name" type="text" oscardb=patient_name>
	</tr>
	<tr>
		<td class="heading2">DOB</td>
		<td class="normaltext"><input class="formtext" name="DateOfBirth" type="text" oscardb=dob></td>
		<td class="heading2">PHN</td>
		<td class="normaltext"><input class="formtext" name="MSP/PHN#" type="text" oscardb=HIN></td>
	</tr>
</table>
</div>


<div name="Diseases">
<table width=100%>
	<tr>
		<td class="heading1">Diseases Incorporated By Complex Care Plan</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="Asthma" type="checkbox">Asthma
			<input name="CVA" type="checkbox">CVD
			<input name="CKD" type="checkbox">CKD
			<input name="COPD" type="checkbox">COPD
			<input name="CHF" type="checkbox">CHF
			<input name="DM" type="checkbox">DM
			<input name="IHD" type="checkbox">IHD
		</td>
	<tr>
		<td class="normaltext">
			<select name="GPSCDxCode">
				<option value="">GPSC Dx Code:</option>
				<option value="A414">A414: Asthma/IHD</option>
				<option value="A428">A428: Asthma/CHF</option>
				<option value="A250">A250: Asthma/DM</option>
				<option value="A430">A430: Asthma/CVD</option>
				<option value="A585">A585:Asthma/CKD</option>
				<option value="A491">A491: Asthma/COPD</option>
				<option value="I428">I428: IHD/CHF</option>
				<option value="I250">I250: IHD/DM</option>
				<option value="I430">I430: IHD/CVD</option>
				<option value="I585">I585: IHD/CKD</option>
				<option value="I491">I491: IHD/COPD</option>
				<option value="H250">H250: CHF/DM</option>
				<option value="H430">H430: CHF/CVD</option>
				<option value="H585">H585: CHF/CKD</option>
				<option value="H491">H491: CHF/COPD</option>
				<option value="D430">D430: DM/CVD</option>
				<option value="D585">D585: DM/CKD</option>
				<option value="D491">D491: DM/COPD</option>
				<option value="C585">C585: CVD/CKD</option>
				<option value="C491">C491: CVD/COPD</option>
				<option value="R491">R491: CKD/COPD</option>
			</select>
		</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="Option"  type="radio" value="Option1">Option 1: 14030 plus visit
			<input name="Option" type="radio" value="Option2">Option 2: 14033 plus block 

care visit
		</td>
	</tr>
</table>
</div>

<div name="Initiation">
<table width="100%">
	<tr>
		<td class="heading1" colspan="2">Initiation of Complex Care</td>
	</tr>
	<tr>
		<td class="heading2">Major Care Plan Date</td>
		<td class="normaltext"><input class="formtext" name="Today" type="text" oscarDB=today></td>
	</tr>
	<tr>
		<td class="heading2">People present at visit</td>
		<td><table name="PeoplePresent" width="100%">
			<tr>
				<td class="heading2"><input name="Patient" type="checkbox">Patient</td>
				<td class="normaltext"><input class="formtext" name="PatientText" type="text" oscarDB=patient_name></td>
			</tr>
			<tr>
				<td class="heading2"><input name="PatientFamily" 

type="checkbox">Patient's Family</td>
				<td class="normaltext"><input class="formtext" 

name="PatientFamilyText" type="text"></td>
			</tr>
			<tr>
				<td class="heading2"><input name="MDPresent" 

type="checkbox">MD</td>
				<td class="normaltext"><input class="formtext" 

name="MDPresentText" type="text" oscarDB=provider_name></td>
			</tr>
			<tr>
				<td class="heading2"><input name="OthersPresent" 

type="checkbox">Other(s)</td>
				<td class="normaltext"><textarea class="formtext" 

name="OthersPresentText" wrap="virtual"></textarea></td>
			</tr>
			</table>
		</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2">
			Included detailed review of patient's:<br>
			<input name="ChartReview" type="checkbox">Chart<br>
			<input name="MedsReview" type="checkbox">Medications
				(<input name="Affordability" type="checkbox">Affordability?
				<input name="PharmacareRegistered" type="checkbox">Pharmacare 

registered?
				<input name="SAFormDone" type="checkbox">S.A. Forms Done?)
		</td>
	</tr>
</table>
</div>
<div name="Linkages">
<table width="100%">
	<tr>
		<td class="heading1">Linkages</td>
	</tr>
	<tr>
		<td class="normaltext"> 
			<input name="Dietician" type="checkbox">Dietician
			<input name="DiabetesEducation" type="checkbox">Diabetes Education
			<input name="RespiratoryEducation" type="checkbox">Respiratory Education
			<input name="HeartRehab" type="checkbox">Heart Rehab
			<input name="HomeCare" type="checkbox">Home Care
			<input name="MentalHealth" type="checkbox">Mental Health
			<input name="Pharmacy" type="checkbox">Pharmacy
			<input name="StopSmokingStrategy" type="checkbox">Stop-smoking 

Strategy<br>
			<input name="SpecialistReferral" type="checkbox">Specialist Referrals<input 

name="SpecialistReferralText" type="text" size="60">
		</td>
	</tr>
</table>
</div>

<div name="Investigations">
<table width="100%">
	<tr>
		<td class="heading1">Investigations</td>
	</tr>
	<tr>
		<td class="normaltext"> 
			<input name="InvestigationsOrdered" type="checkbox">See ordered 

investigations</td>
	</tr>
</table>
</div>



<div name="ComplexCarePlanDetails">
<table width=100%>
	<tr>
		<td class="heading1">Complex Care Plan Details</td>
	</tr>
	<tr>
		<td class="normaltext">Please refer to the <a href="http://bcguidelines.ca/" 

target="_blank">BC Clinical Practice Guidelines and Protocols</a></td>
	</tr>
	<tr>
		<td class="normaltext"><input name="ReviewedGuidelines" type="checkbox">Reviewed 

patient care guidelines</td>
	<tr>
		<td class="normaltext">
			<textarea name="Comments" class="formtext" wrap="virtual" style="height: 

200px"></textarea>
		</td>
	</tr>
</table>
</div>



<div name="PatientGoals">
<table width="100%">
	<tr>
		<td class="heading1" colspan="2">Patient Goals</td>
	</tr>
	<tr>
		<td class="normaltext"> 
			<input name="StopSmoking" type="checkbox">Stop Smoking<br>
			<input name="StopSmokingWithAPlan" type="Checkbox">Stop Smoking With a 

Plan<br>
			<input name="Weight Loss" type="checkbox">Weight Loss<br>
			<input name="WeightLossWithAPlan" type="checkbox">Weight Loss With a 

Plan<br>
			<input name="Exercise" type="checkbox">Exercise<br>
			<input name="ExerciseWithAPlan" type="checkbox">Exercise With a Plan<br>
			<input name="WeightTracking" type="checkbox">Weight Tracking<br>
		</td>
		<td class="normaltext">

			<input name="BetterDiabeticControl" type="checkbox">Better Diabetic 

Control<br>
			<input name="ConformingWithMeds" type="checkbox">Conforming with 

Meds<br>
			<input name="A1C7" type="checkbox">A1C < 7<br>
			<input name="A1C6" type="checkbox">A1C < 6<br>
			<input name="RegLabs" type="checkbox">Regular Labs<br>
			<input name="BPControl" type="checkbox">BP 120/80 or better<br>
		</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2">
			<input name="OthersGoals" type="checkbox">Others:
			<textarea name="OtherGoalsText" class="formtext" style="height: 

50px;"></textarea>
		</td>
	</tr>
</table>
</div>



<div name="ExpectedOutcomes">
<table width=100%>
	<tr>
		<td class="heading1">Expected Outcomes</td>
	</tr>
	<tr>
		<td class="normaltext">
		<input name="DecreaseERVisits" type="checkbox">Decrease Emergency Visits
		<input name="DecreaseHospitalAdmission" type="checkbox">Decreased Hospital Admission
		<input name="ImproveQOL" type="checkbox">Improve Quality of Life
		<input name="DecreasePrematureDeath" type="checkbox">Decrease Premature Death
		</td>

	</tr>
	<tr>
		<td class="normaltext"><input name="OtherOutcomes" type="checkbox">Others:
			<textarea name="OtherOutcomesText" class="formtext" style="height: 

100px;"></textarea></td>
	</tr>
</table>
</div>

<div name="AdvancedCare">
<table width="100%">
	<tr>
		<td class="heading1">Advanced Care Directive</td>
	</tr>
	<tr>
		<td class="normaltext"> 
			<input name="DNR" type="checkbox">Do Not Resuscitate
			<input name="LivingWill" type="checkbox">Living Will
			<input name="FamilyAware" type="Checkbox">Family Aware<br>
			<input name="OthersAdvancedCare" type="checkbox">Others:
			<textarea name="OtherAdvancedcareText" class="formtext" style="height: 

50px;"></textarea>
		</td>
	</tr>
</table>
</div>

<div name="ReEvaluation">
<table width="100%">
	<tr>
		<td class="heading1">Re-Evaluation</td>
	</tr>
	<tr>
		<td class="normaltext"> Re-evaluation in <input type="text" size="10" value="1 year">
		</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="CarePlanGiven" type="checkbox">Copy of care plan given to 

patient
		</td>
	</tr>
</table>
</div>


<br>
<br>

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</tr>
</table>
</div>

</form>
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</body>
</html>
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