University of Cincinnati Academic Health Center Encounter Sheet

Toolkit for Implementing the Chronic Care Model in an Academic Environment

Each of the four pilot sites adapted the basic concepts underlying the planned visit approach to meet the unique needs of the team and patient population. The Hoxworth internal medicine-pediatric team created an electronic encounter sheet to identify diabetic patients involved in the planned visit pilot program. The team can access general data organized demographically, by planned visit, and by most current test results. Physicians are also able to access data arranged around their patient base and by specific report.

The Hoxworth Adult Medicine Encounter Sheet. For details, go to [D] Text Description.

Text Description

The Hoxworth Adult Medicine Encounter Sheet is separated into four main sections. In the section on the left is a column of information divided into three subsections where the viewer can input data: Vitals: Date, Weight, Height, Pulse, Resp Rate, Temp, Systolic BP, Diastolic BP, BMI, Waist Circ In. It also presents the date of and vitals from the patient's last visit.

The subsection beneath it is entitled "Chronic Conditions" and lists these categories that may be checked off: Diagnosed Conditions: DM Type 2, Dyslipidemia, Hypertension There is also an option to input the diagnosis date and whether diagnosis has been resolved. A new subheading is under this part: Potential Conditions: CAD, CHF, DepressedNOS, MetabSyndrome, MicAlburia, Nephropathy, Neuropathy, Post-MI, PVD, Retinopathy. There are boxes that enable the user to add these conditions to the record.

The next subsection is entitled "Medications" and includes options for selecting whether the medications will be discontinued, contra-indicated, or declined by the patient. There are four classes of medications given at the top and the Class, Name, and Date are given as identifying options: ACE Inhibitor, Biguanides, Statins, Sulfonylurea. This is followed by "Other Medications to Consider": AG Inhibitor Antiplat/thromb ARB Beta Blocker Calc Chan Bio DHP-CCB Diuretic Fibrate Glitinides Insulin NDH-CCB Niacin Other BP Med TZD/Glitazon.

At the top of the screen and to the right is a rectangular box that has fields for entering data on the following items: Encounter Provider, Encounter Type, Chart #, Last name, First name, Middle initial, Age, Date of Birth, Sex, Address, City, State, Zip Code, Phone number, language, emergency contact, emergency contact number, PCP, case manager, race, insurance, homeless, migrant, Social Security number, Fed Pov Lvs, Pop of focus mbr.

Beneath this box are two columns. On the left-hand side the column is separated into four subsections: Laboratory Test Results, Other Diagnostic tests, Vaccinations and Immunizations, and Risk Factors.

  • Under Laboratory Test Results are the following options: Test, Value, Date, Previous Referral, Referral, and Declined. The tests listed in this subsection are: ALT BUN Calcium Carbon Dioxide Chloride Chol Creat Fast Glucose GFRAA GFRNonAA HbA1c HDL LDL MiAI/Cr Potassium Sodium Triglyc.
  • Under Other Diagnostic Tests are the following options: Test, Result, Date, Previous Referral, Referral, and Declined. The tests listed under this subsection are: CardioStrss Test ColonCaScreen Echo EKG Mammogram OGTT Pap Smear.
  • Under Vaccinations and Immunizations are the following options: Vac/Imm, Date, Previous Referral, Referral, Declined. Under Vac/Imm are the following: Flu Vac Hep B vac #1 IPV/OPV #1 PPV23.
  • Under Risk Factors are the following: Family History, Behaviors, and Status, along with options to select "yes", "no", "unknown", "current", "never", and "never".
    • The category under Family History is "FamHxDM"
    • The category under Behaviors is "SM BG", "TobaccoETS", "TobUse/Smoke".

The last section is divided into four subsections: Other Measures, Consults and Education, Other Notes, and Reminders.

  • Under Other Measures are the following headings: Test, Value, Date, Previous Referral, Referral, and Declined. Under test is "Exercise wk" and LVEF.
  • Under Consults and Education are the following headings: Cons/Edu, Date, Previous Referral, Referral, and Declined. Under Cons/Edu are these categories: Ca S-D making CVD Educ Dental Exam Depression Scrn DM Edu Foot Exam Nutrit Edu PCPDentalCnst Retinal Exam SM Goal Set WT Mgt Plan.
  • Under Other Notes are the following options: Encount Note: Meter Type: SM Goal Des.
  • Under Reminders are "ColonCaScreen 1" and "Pap Smear 1"

There is also a list of patient details, including name, address, insurance, vitals, chronic conditions, medications, laboratory and diagnostic test results, vaccinations and immunization.

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Page last reviewed January 2008
Internet Citation: University of Cincinnati Academic Health Center Encounter Sheet: Toolkit for Implementing the Chronic Care Model in an Academic Environment. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic3a11a.html