Care Plan Review

Care Plan Review Review of care plan created by facility on 01/15/2023 Diagnoses have been reviewed and updated as appropriate. Past Medical History Date of medical history: 01/10/2023 Active medical conditions: Hypertension (diagnosed 03/2018), Type 2 Diabetes (diagnosed 06/2020) Inactive medical conditions: Asthma (resolved 05/2015) Relevant diagnostic tests or procedures: HbA1c 7.2% (01/05/2023), Blood Pressure 130/85 mmHg (01/10/2023) Advance health directive details: Patient has a living will dated 02/20/2020 Medications Current medications: Metformin 500mg twice daily, Lisinopril 10mg once daily Patient's PMC checked for up-to-date medication list Immunisation Influenza vaccine 10/2022, COVID-19 booster 11/2022 Allergies Penicillin PsychoSocial History and Functional Assessment Advance care directive status: Active COVID vaccine status: Up to date Care providers: Dr. Sarah Lee (Endocrinologist), Dr. John Smith (Cardiologist) Details of GP visits: Last visit on 01/10/2023 Significant Events Since last review: Hospital admission for chest pain on 12/15/2022, medication adjustment on 01/05/2023 Recommendations / Actions Additional recommendations to the care plan: Increase physical activity to 30 minutes daily Instructions for monitoring weight changes: Weigh weekly Record of recent weight measurements: 180 lbs on 01/10/2023 Acceptable BP range for the patient: 120-140/80-90 mmHg Instructions for monitoring blood glucose levels: Check fasting glucose daily Instructions for pain assessment and management: Use pain scale at each visit INR management instructions: Not applicable Instructions for urinalysis and interpretation: Monthly urinalysis for microalbumin Specific monitoring or considerations based on patient's condition: Monitor for signs of hypoglycemia Psychotropic medication status and review requirements: Not applicable EPC referrals: Not required at time of review Signature of the reviewing doctor: Dr. Thomas Kelly Date of review: 01/15/2023 Instructions for filing and sharing the document: File in patient's electronic health record and share with care team via secure email.