Get Aafp Transitional Care Management 30-day Worksheet 2013-2025

Filling out the AAFP Transitional Care Management 30-Day Worksheet is an essential step in ensuring effective patient follow-up and care transition. This guide provides a clear and concise approach to completing the worksheet online, ensuring all relevant components are accurately captured.

Follow the steps to complete the worksheet successfully.

1. Press the ‘Get Form’ button to obtain the AAFP Transitional Care Management 30-Day Worksheet and open it in your online document editor.
2. Fill in the 'Patient name' field with the full name of the patient and include their 'DOB' (date of birth).
3. Complete the 'D/C physician' (discharge physician) section along with the 'D/C date' (discharge date) to ensure proper identification of the attending physician and the date of discharge.
4. In the 'Records requested' section, specify which medical records you need for the transition process.
5. In the 'Records received' section, document the records that have been obtained post-discharge.
6. Indicate whether the records have been 'Reviewed' by marking the appropriate field as needed.
7. List the 'Diagnoses on discharge' to provide clarity on the patient's condition at the time of discharge.
8. Note the 'Date of interactive contact' within two business days post-discharge and specify the mode of contact, such as phone, email, direct contact, or other.
9. Record the date of either the 7-day or 14-day face-to-face visit, and indicate if family and/or caretaker were present during the visit.
10. Fill out the 'Medications on discharge' to document all medications the patient was prescribed.
11. Include any 'Medication changes/adjustments' that have occurred since discharge.
12. In the 'Diagnostic tests reviewed/disposition' section, document all tests that have been reviewed and their results.
13. Note any 'Disease/illness education' provided to the patient.
14. Discuss any 'Home health/community services' referrals made or services provided.
15. Ensure the 'Establishment or re-establishment of referral orders for community resources' is accurately recorded.
16. Document all discussions held with other health care providers regarding the patient's care.
17. Assess the patient's adherence to the treatment regimen and provide support where necessary.
18. Coordinate any follow-up 'Appointments' that have been scheduled.
19. Complete the 'Education for self-management' section to ensure the patient is informed about their daily activities and living.
20. At the conclusion, save any changes made, download or print the worksheet, and share it accordingly to fulfill submission requirements.

Complete your AAFP Transitional Care Management 30-Day Worksheet online to ensure effective patient care transitions.