2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Care Coordination11. Prevention Screening, Patient Education <strong>and</strong>Counseling (Physical Health Only)Documentation is present as applicable forproblems <strong>and</strong> current diagnosis. For Medicaidrecipients, the status of preventive services, or atleast those specified by the NMHSD, must besummarized on a single sheet in the medical recordwithin six months of enrollment. Lifestylemanagement <strong>and</strong> preventive health careinformation must be documented <strong>and</strong> includes butis not limited to the information in the list below. Acomprehensive list of screening <strong>and</strong> counselingtopics is available in the <strong>Presbyterian</strong> Preventive<strong>Healthcare</strong> Guidelines for practitioners athttp://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001475.pdf.Family planningCancer prevention <strong>and</strong> detection (such as sunexposure <strong>and</strong> breast, cervical, testicular, <strong>and</strong>colon cancer screenings, as appropriate)Injury prevention – at least one of thefollowing:• Vehicle safety belts• Occupational hazards• Home safetySmoke alarmsPromotion of preventive health care screening<strong>and</strong> counselingHIV infection <strong>and</strong> other sexually transmitteddiseasesTobacco useAlcohol <strong>and</strong> substance use/abuseOsteoporosis <strong>and</strong> heart disease inmenopausal womenMotor vehicle injuriesHousehold <strong>and</strong> recreational injuriesDental <strong>and</strong> periodontal diseaseUnintended or mistimed pregnanciesObesityPhysical activityHealthy diet12. Durable Power of Attorney/Advance Directives(Physical Health Only)Documentation must be present in the medicalrecord that each adult patient was offeredinformation on durable power of attorney/advancedirectives. The documentation should be signed<strong>and</strong> dated by the patient <strong>and</strong> the practitioner <strong>and</strong> bemaintained in the patient medical record. Anadvance directive form is available on the<strong>Presbyterian</strong> website athttps://www.phs.org/providers/cliniciansresources/Pages/health-services.aspxunderMedical Record St<strong>and</strong>ards <strong>and</strong> Requirements.13. Patient Notification of Abnormal Diagnostic TestResults (Physical Health Only)Patients must be notified of abnormal diagnostictest results <strong>and</strong> the scheduled follow-up visit, plans,<strong>and</strong>/or directions.14. Consultations/ReferralsDocumentation must be present in themedical record regarding medical care,services, <strong>and</strong> results for consultations.6-232014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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