John Doe is a 67-year-old male patient with a PMH listed below presents to complete their Medicare Well Visit today, for routine check-up, and preventive services.
Patient Active Problem List:
- Hypertension
- Type 2 Diabetes
- Hyperlipidemia
Social History
Tobacco Use
Non-smoker
No smokeless tobacco usage
Visit Type: Medicare Well Visit
Demographics verified
Social Connection and Isolation Screening: No issues reported
Patient Care Team:
- Dr. Sarah Johnson, Cardiologist
- Dr. Emily White, Endocrinologist
Patient's self-rated health status: Good
Recent hospital discharge information: None
Date of Discharge: N/A
Recent emergency room or urgent care visit information: None
Date of Visit: N/A
Significant previous hospital stays, injuries, or treatment information: None
Home Safety:
Tub or shower safety assessment: Safe
Tub or shower safety counseling: Not applicable
Toilet support assessment: Safe
Toilet support counseling: Not applicable
Rug safety assessment: Safe
Rug safety counseling: Not applicable
Floor clutter assessment: Safe
Floor clutter counseling: Not applicable
Fall history information: No falls reported
Morse Fall Risk Score: 0
Get-up-and-go-test: Normal
Detailed observations of patient's ability to rise from a chair: No issues observed
Oral health:
Dentist visit information: Last visit 6 months ago
Dentures present:
Upper denture information: None
Lower denture information: None
Screening Tools:
Depression screening status and result: Negative
ADL & IADL screening status and result: No deficiencies
ADL or IADL deficiencies not linked to physical limitations assessment: None
Confusion or memory loss assessment: No issues reported
MINI-COG completion status: Completed, normal
Advance Directive:
Health Care Proxy: Assigned to spouse, Jane Doe
Medication reconciliation status: Completed, no discrepancies
