FPM Toolbox
Care Management
Download tools to help you manage patient care tasks, from agenda-setting to controlled substance refills.
A Deprescribing Algorithm |
| A set of steps to follow in deprescribing medications |
| Download Format: PDF |
| Source Article |
Agenda-Setting Algorithm |
| An algorithm that details the steps involved in setting a visit agenda with the patient |
| Download Format: PDF |
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Ambulatory Patient Checklist for MAs |
| A checklist designed to help medical assistants and other midlevel providers remember key steps in a patient's visit |
| Download Format: PDF |
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Ask-Tell-Ask Framework for Flu Vaccination |
| A three-step process, with examples, for how physicians can discover, understand, and resolve patients' concerns about getting a flu shot |
| Download Format: PDF |
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Chronic Care Management Patient Agreement Form |
| A form that facilitates billing Medicare for chronic care management services |
| Download Format: PDF |
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Chronic Care Management Patient Letter |
| A letter that explains chronic care management services to patients |
| Download Format: PDF |
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Chronic Care Management Services Log |
| A spreadsheet that facilitates tracking the time and activities associated with chronic care management services for Medicare billing purposes |
| Download Format: Excel |
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Community-Based Organization Referral Form |
| A template for providing the essential information needed when referring patients to community-based organizations |
| Download Format: PDF |
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Controlled Substance Refill Program: Patient Agreement Form |
| An agreement patients sign indicating they understand and will comply with the practice's rules for opioid use |
| Download Format: PDF |
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Controlled Substance Refill Program: Patient Enrollment Form |
| A form used to enroll patients in a practice's program for managing controlled substance refills |
| Download Format: PDF |
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Emergency Supplies Checklist for Family Medicine Offices |
| A list of medical equipment, medications, and other supplies that may be needed during an office emergency |
| Download Format: PDF |
| Source Article |
Exercise Diary |
| A diary to help patients track their daily exercise |
| Download Format: PDF |
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Food Diary |
| A diary to help patients track what they've eaten to aid in weight loss or other health matters |
| Download Format: PDF |
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General Symptom Diary |
| A diary to help patients track general symptoms to aid in diagnosis |
| Download Format: PDF |
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Headache Diary |
| A diary to help patients track their headache symptoms |
| Download Format: PDF |
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Health Confidence Measure |
| A tool for assessing patients' confidence in their ability to control and manage their health problems |
| Download Format: PDF |
| Source Article |
Immunization Reminder Letter |
| A letter to remind parents/guardians that a child is due for immunizations |
| Download Format: PDF |
| Source Article |
Mock Emergency Evaluation Form |
| A form for evaluating your practice's response to a mock emergency situation |
| Download Format: PDF |
| Source Article |
Patient-Centered Care Plan |
| A form designed for use when providing chronic care management services to Medicare patients |
| Download Format: PDF |
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Preventive Visit Algorithm: Patients Ages 18-64 |
| A summary of preventive services suggested for patients ages 18 to 64 years |
| Download Format: PDF |
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Previsit Planning Checklist |
| A checklist used by the medical assistant to identify potential care gaps and otherwise better prepare for an upcoming patient appointment. |
| Download Format: PDF |
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Quality Measures for Primary Care |
| This compilation of common quality measures can serve as a checklist for primary care physicians |
| Download Format: PDF |
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Refugee Health Checklist |
| A checklist summarizing the components practices should have in place when caring for refugees. |
| Download Format: PDF |
| Source Article |
Sleep Diary |
| A diary to help patients track their sleep patterns |
| Download Format: PDF |
| Source Article |
Standing order for medication refills |
| A standing order including the rules for non-physicians to refill patient medication, as an example of standing orders in general. |
| Download Format: PDF |
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The "FAVER" Approach: Responding to Inappropriate Patient Requests |
| A five-step framework for responding to inappropriate requests from patients |
| Download Format: PDF |
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Tracking Book for Unresolved Issues |
| An example of a tracking book that can be used as a reminder for following up on patients' test results or other unresolved issues |
| Download Format: PDF |
| Source Article |
Upper Respiratory Tract Infection Telephone Triage Form |
| A nurse triage form to prepare for the annual flu season |
| Download Format: PDF |
| Source Article |
Voiding Diary |
| A diary to help patients track their voiding patterns |
| Download Format: PDF |
| Source Article |
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