Dot Phrases

Patient seen today for longitudinal care of complex/chronic conditions. This visit serves as a focal point for the patient's ongoing care management.

TCM Service (14-day). Patient discharged from [Facility] on [Date]. Contact made within 2 business days by [Name] via [Phone/Portal]. Medication reconciliation completed. Face-to-face visit completed today (Day [X] post-discharge). Moderate complexity decision making regarding [Conditions].

TCM Service (7-day). Patient discharged from [Facility] on [Date]. Contact made within 2 business days by [Name] via [Phone/Portal]. Medication reconciliation completed. Face-to-face visit completed today (Day [X] post-discharge). High complexity decision making established.

Initial Annual Wellness Visit performed. HRA reviewed and completed. Medical/Family history updated. Current providers listed. Vitals recorded: Ht [X] Wt [X] BP [X] BMI [X]. Cognitive impairment screen: Negative. Depression screening (PHQ-9): Score [X]. Functional ability/safety screen: No concerns. Personalized prevention plan created and provided to patient.

Subsequent Annual Wellness Visit. HRA reviewed and updated. Medical/Family history updated. Current provider list reviewed. Vitals: Wt [X] BP [X]. Cognitive function assessed: [Normal/Concern noted]. Screening schedule updated. Prevention plan updated.

Advance Care Planning counseling provided (25 minutes face-to-face) with patient [and surrogate/family member]. Topics covered: disease trajectory, prognosis, goals of care. Advance Directives, Living Will, and DPOA-HC explained. Code status reviewed: DNR/DNI vs Full Code vs Limited Interventions. Patient expressed wish for [Comfort-focused/Aggressive/Quality of life]. Forms [provided/completed/scanned into chart]. Patient understands these can be revoked at any time.

Informed consent obtained and documented. Site [Left/Right Knee/Shoulder/Hip] prepped with Betadine in sterile fashion. Gloves worn. 20g needle used via [lateral/anterior/posterior] approach. Aspirated [X cc of fluid / no effusion] prior to injection. Injected 40mg Kenalog + 4cc 1% Lidocaine without resistance. Needle withdrawn, pressure applied, bandaid placed. Patient tolerated well without complications. Post-injection instructions given. Follow up in [4-6 weeks].