CCM Logs: Adolphus Williams

ADOLPHUS
WILLIAMS
Age: 51 Phone No. 7133494145

DOB. 08/05/1970 EMR No. 13114
CCM Logs CCM Completed Time: 00:23:00
Service Type Monthly Clinical Review
Description Called the patient for monthly CCM review, and discussed all the health conditions.Reviewed patient's EMR,Patient’s medications were
reconciled and allergies were confirmed. Confirmed the Diagnoses. Patient has Hypertension(chronic disease) We made the followup on patient’s last
office visit complaint. Patient was advised to continue medications, Pt had a f/u with Dr last month and had his blood work done aswell. Pt A1C was 6.4
and cholesterol was on higher side. Advised pt for a healthy diet. Pt needed refill on potassium. Patient monitor the BP and reports blood pressure has
12/10/2021 been running normal, Patient was advised to keep a log of BP so the condition can be better managed. Patient was advised to watch sodium intake.
Patient was advised to start on healthy diet pattern and to avoid carbs/starch in this daily routine, instead have more green vegetables. Patient was
educated on how to read food labels and make healthy choices.Patient stated that has not had a fall in the past 1 year. We discussed about the fall
prevention plans. No Hospitalization reported in past one month. Patient Denies SOB, chest pain, dizziness, weakness or any loss in appetite. Follow
up for the next call has been set up.
Created By: Ayesha Imam Start Time: 02:42 Duration: 00:21:00
Service Type Telephone Call with patient
12/9/2021 Description No answer
Created By: Ayesha Imam Start Time: 01:19 Duration: 00:02:00
Interventions Chronic Diseases
Diabetes
Patient/Caregiver has an understanding of blood glucose testing as ordered and/or for s/s of exacerbation Date:06/10/2021 Status:Met
Description Status:Active
If results are less than 70, take ½ cup fruit juice, ½ cup regular (not diet) soft drink, 8 oz of milk, 57 pieces of hard candy (not sugar free), or 2 teaspoons of sugar or
honey and follow with balanced meal. Recheck blood sugar in 30min.
instruct on how to check sugar at home
Patient/Caregiver has an understanding of recognizing signs and symptoms of diabetes that must be reported to the doctor Date:05/14/2021 Status:Met

or nurse
Instructed on critical symptoms of imminent danger, and educated to act immediately if patient feels nauseated, weak, and excessively thirsty; has increased confusion;
is urinating very frequently; has abdominal pain; is breathing more deeply and rapidly than normal perhaps with sweet breath that smells like nail polish remover
patient may need immediate medical attention for ketoacidosis a potentially deadly complication of type 1 diabetes.
Instruct in recognition of signs and symptoms of diabetes that must be reported including: common signs/symptoms of diabetes should be reported and include:
excessive thirst and appetite, increased urination (sometimes as often as every hour), unusual weight loss or gain, fatigue, nausea, perhaps vomiting, and blurred vision.
In women, frequent vaginal infections. In men and women, yeast infections, dry mouth, slowhealing sores or cuts or itching skin, especially in the groin or vaginal area
Patient/Caregiver has an understanding of selfmanagement and wellness principles related to diabetes. Date:11/09/2021 Status:Met
Go for fibre. You get fibre from plant foods: whole grains, fruits, vegetables, beans, and nuts. Studies suggest that people with diabetes who eat a highfibre diet can
improve their blood sugar control and cholesterol levels.
Stress raises blood pressure and stress hormones that raise blood glucose levels and magnify diabetic problems. How to recognise and relieve stress. Including
techniques such as relaxed breathing, a hobby, or exercise.
Keep in mind that blood sugar results often trigger strong feelings. Blood sugar numbers can sometimes make you upset, confused, frustrated, angry or down. It is easy
to use the numbers to judge yourself. Remind yourself that your blood sugar level is a way to track how well your diabetes care plan is working. It is not a judgment of
you as a person. The results may show you need a change in your diabetes plan. Page: 1 of 5
Stress raises blood pressure and stress hormones that raise blood glucose levels and magnify diabetic problems. How to recognise and relieve stress. Including
techniques such as relaxed breathing, a hobby, or exercise.
Keep in mind that blood sugar results often trigger strong feelings. Blood sugar numbers can sometimes make you upset, confused, frustrated, angry or down. It is easy
to use the numbers to judge yourself. Remind yourself that your blood sugar level is a way to track how well your diabetes care plan is working. It is not a judgment of
you as a person. The results may show you need a change in your diabetes plan.
Obtain a medical alert bracelet to designate that you are diagnosed with diabetes. This may help expedite treatment from emergency services personnel if you
experience your blood sugar is too low and you are unable to speak.
Patient/Caregiver has an understanding on diabetic dietary guidelines Date:07/26/2021 Status:Met
Instruct on patientspecific dietary guidelines/needs/restrictions including how to read food labels using examples from their own pantry or refrigerator, including: diet as
ordered by physician (** specify), don't get stuck in a rut. Choose foods of different colors. That's an easy way to make sure that you are eating plenty of fruits,
vegetables, whole grains, beans, nuts, and lean protein.
Instructed on serving size suggestions per the ADA guidelines or as ordered by physician
Do not skip meals. Eat meals and snacks at regular times every day. If you are taking a diabetes medicine, eat your meals and take your medicine at the same times
each day.
In people with type 2 diabetes, extra body fat means less sensitivity to insulin.
Be sure to eat only the amount of food in your diabetes meal plan. Extra calories lead to extra fat and pounds.
Hypertension
Patient/Care giver has an understanding regarding high blood pressure. Date:10/12/2021 Status:Met
When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health
threats.
Using medications as prescribed and making positive lifestyle changes can help enhance your quality of life and reduce your risk of heart disease, stroke, kidney disease
and more
Implement dietary, sodium and cholesterol restrictions as indicated. These restrictions can help manage fluid retention, and with hypertensive response, decrease
cardiac workload.
Patient/Caregiver has been taught regarding the methods to track blood pressure readings. Date:03/11/2021 Status:Met
Monitor and record BP reading on a daily basis or as instructed by your physician.
Maintain a BP log. Templates available on the American Heart Association website. A record of readings taken over time provides a “timelapse” picture of your blood
pressure that can help you partner with your physician to ensure that your treatments to lower high blood pressure (HBP or hypertension) are working.
Obtain a BP cuff and follow manufacture instructions on use.
Patient/Caregiver has an understanding regarding techniques to reduce edema/fluid overload. Date:09/18/2021 Status:Met
Patient on long term consequences of edema, specifically ***
Take multiple readings and record the results. Each time you measure, take two or three readings one minute apart and record the results using a printable or online
tracker. If your monitor has builtin memory to store your readings, take it with you to your appointments. Some monitors may also allow you to upload your readings to a
secure website after you register your profile.
Need to have a baseline weight or measurements and document them where they can be easily accessed. Baseline weight/measurement is *****
Obesity
Page: 2 of 5
Patient/Caregiver has an understanding regarding risk factors associated with Obesity. Date:12/10/2021 Status:Met
Status:Active
Need to have a baseline weight or measurements and document them where they can be easily accessed. Baseline weight/measurement is *****
Obesity
Patient/Caregiver has an understanding regarding risk factors associated with Obesity. Date:12/10/2021 Status:Met
Obesity is a risk factor of Gout and gouty arthritis
Obesity is a risk factor of Osteoarthritis (degenerative arthritis) of the knees, hips, and the lower back.
Obesity is a risk factor of Sleep apnea.
Primary Care Provider
# Care Provider Name Contact Number Email Address

1 Kamran Khan 9366410434 khan@urgentcaremds.com
Other Care Provider
# Care Provider Name Contact Number Email Address

1 Ayesha Imam ayesha.imam@2chealthsolutions.com
Medical Conditions
# ICD Code ICD Description Notes Is Chronic Diagnose Date Resolve Date

1 I10 Essential (primary) hypertension Yes
2 E11.65 Type 2 diabetes mellitus with hyperglycemia Yes
3 Z68.42 Body mass index [BMI] 45.049.9, adult Yes
4 I42.9 Cardiomyopathy, unspecified Yes
5 I42.0 Dilated cardiomyopathy Yes
6 Z68.44 Body mass index [BMI] 60.069.9, adult Yes
7 I50.9 Heart failure, unspecified Yes
8 G56.00 Carpal tunnel syndrome, unspecified upper limb Yes
9 E87.6 Hypokalemia Yes
10 E78.00 Pure hypercholesterolemia, unspecified Yes
11 E66.01 Morbid (severe) obesity due to excess calories Yes
Medications
# Medication Name Brand Name Dose

1 isosorbide dinitrate 10 mg tablet 2 tab(s) orally 3 times a day.
2 atorvastatin 40 mg tablet 1 tab(s) orally once a day (at bedtime).
3 carvedilol 12.5 mg tablet 1 tab(s) orally 2 times a day.
4 hydralazine 25 mg tablet 1 tab(s) orally 3 times a day.
5 metolazone 2.5 mg tablet 1 tab(s) orally once a day.
6 magnesium oxide 400 mg tablet 1 tab(s) orally three a day.
7 spironolactone 25 mg tablet 1 tab(s) orally 2 times a day, Notes: taking it qd.
8 torsemide 20 mg tablet 1 tablet orally once a day.
9 digoxin 250 mcg (0.25 mg) tablet 1 tab(s) orally once a day.
10 potassium chloride 20 mEq tablet, extended release 1 tab(s) orally 2 times a day.
11 Farxiga 5 mg tablet 1 tab(s) orally once a day.
12 MiraLax powder for reconstitution as directed orally once a day. orally once a day.
Page: 3 of 5
13 Colace sodium 100 mg capsule 1 cap(s) orally 2 times a day.
8 torsemide 20 mg tablet 1 tablet orally once a day.
9 digoxin 250 mcg (0.25 mg) tablet 1 tab(s) orally once a day.
10 potassium chloride 20 mEq tablet, extended release 1 tab(s) orally 2 times a day.
11 Farxiga 5 mg tablet 1 tab(s) orally once a day.
12 MiraLax powder for reconstitution as directed orally once a day. orally once a day.
13 Colace sodium 100 mg capsule 1 cap(s) orally 2 times a day.
Allergies
# Agent Clinical Status Category Criticality Reaction Type
Immunization
# Vaccination Code Date Notes
Care Plan
I have challenges with
Other Comment
No challenges
My Religion/Spirituality impacts my health care
No
Other Comment
Healthcare Advance Directives:
Yes
Other Comment
Physician Orders for Life Sustaining Treatment (POLST):
No
Other Comment
Power of Attorney (Financial / Healthcare):
Yes
Other Comment
I live:
Partner/Spouse
I learn best by:
Being talked to
Other Comment
I have access to the Internet:
Yes
I have issues with Diet:
No
Other Comment
I am concerned about:
My ability to manage my chronic condition
How satisfied I am with the current medical care:
I want to improve on:
Is G0506 eligible:
No Page: 4 of 5
8
I want to improve on:
Is G0506 eligible:
No
Page: 5 of 5

CCM Logs: Adolphus Williams

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ADOLPHUS

Age: 51 Phone No. 7133494145

Created By: Ayesha Imam Start Time: 02:42 Duration: 00:21:00

Created By: Ayesha Imam Start Time: 01:19 Duration: 00:02:00

Patient/Caregiver has an understanding of blood glucose testing as ordered and/or for s/s of exacerbation Date:06/10/2021 Status:Met

Patient/Caregiver has an understanding of recognizing signs and symptoms of diabetes that must be reported to the doctor Date:05/14/2021 Status:Met

Patient/Caregiver has an understanding of selfmanagement and wellness principles related to diabetes. Date:11/09/2021 Status:Met

Patient/Caregiver has an understanding on diabetic dietary guidelines Date:07/26/2021 Status:Met

Patient/Care giver has an understanding regarding high blood pressure. Date:10/12/2021 Status:Met

Patient/Caregiver has been taught regarding the methods to track blood pressure readings. Date:03/11/2021 Status:Met

Patient/Caregiver has an understanding regarding techniques to reduce edema/fluid overload. Date:09/18/2021 Status:Met

Patient/Caregiver has an understanding regarding risk factors associated with Obesity. Date:12/10/2021 Status:Met

# Care Provider Name Contact Number Email Address

# Care Provider Name Contact Number Email Address

# ICD Code ICD Description Notes Is Chronic Diagnose Date Resolve Date

# Medication Name Brand Name Dose

# Agent Clinical Status Category Criticality Reaction Type

# Vaccination Code Date Notes

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CCM Logs: Adolphus Williams

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CCM Logs: Adolphus Williams

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ADOLPHUS

Age: 51 Phone No. 7133494145

Created By: Ayesha Imam Start Time: 02:42 Duration: 00:21:00

Created By: Ayesha Imam Start Time: 01:19 Duration: 00:02:00

Patient/Caregiver has an understanding of blood glucose testing as ordered and/or for s/s of exacerbation Date:06/10/2021 Status:Met

Patient/Caregiver has an understanding of recognizing signs and symptoms of diabetes that must be reported to the doctor Date:05/14/2021 Status:Met

Patient/Caregiver has an understanding of self­management and wellness principles related to diabetes. Date:11/09/2021 Status:Met

Patient/Caregiver has an understanding on diabetic dietary guidelines Date:07/26/2021 Status:Met

Patient/Care giver has an understanding regarding high blood pressure. Date:10/12/2021 Status:Met

Patient/Caregiver has been taught regarding the methods to track blood pressure readings. Date:03/11/2021 Status:Met

Patient/Caregiver has an understanding regarding techniques to reduce edema/fluid overload. Date:09/18/2021 Status:Met

Patient/Caregiver has an understanding regarding risk factors associated with Obesity.​ Date:12/10/2021 Status:Met

# Care Provider Name Contact Number Email Address

# Care Provider Name Contact Number Email Address

# ICD Code ICD Description Notes Is Chronic Diagnose Date Resolve Date

# Medication Name Brand Name Dose

# Agent Clinical Status Category Criticality Reaction Type

# Vaccination Code Date Notes

You might also like

Patient/Caregiver has an understanding of selfmanagement and wellness principles related to diabetes. Date:11/09/2021 Status:Met

Patient/Caregiver has an understanding regarding risk factors associated with Obesity. Date:12/10/2021 Status:Met