Continuity of Care Record

Continuity of Care Record

Date Created: EEE MMM dd, yyyy 'at' hh:mm aa zzz
From: ( )
To: ( )
Purpose:

Patient Demographics
Name Date of Birth Gender Identification Numbers Address / Phone

:


,

:
Alerts
Type Date Code Description Reaction Source
- #
Advance Directives
Type Date Description Status Source
#
Support Providers
Role Name
#
Functional Status
Type Date Code Description Status Source
#
Problems
Type Date Code Description Status Source
#
Procedures
Type Date Code Description Location Substance Method Position Site Status Source
( - )
#
Medications
Medication Date Status Form Strength Quantity SIG Indications Instruction Refills Source
( )
/


#
Immunizations
Code Vaccine Date Route Site Source
( )
#
Vital Signs
Vital Sign Date Result Source
MMM dd, yyyy ':' hh:mm aa zzz
#
Encounters
Type Date Location Status Practitioner Description Indications Source



#
Social History
Type Date Code Description Status Source
#
Family History
Type Date Code Description Relationship(s) Status Source
#
Results (Discrete)
Test Date Result Source
MMM dd, yyyy ':' hh:mm aa zzz
#
Results (Report)
Test Date Result Source
MMM dd, yyyy ':' hh:mm aa zzz
#
Insurance
Type Date Identification Numbers Payment Provider Subscriber Source
MMM dd, yyyy ':' hh:mm aa zzz
:
:
# # #
Plan Of Care Recommendations
Description Recommendation Goal Status Source
#
Plan Of Care Orders
Descripion Plan Status Type Date Procedure Schedule Location Substance Method Position Site Status Source
Every for
#
Health Care Providers
Role Name
#
References
Type Date Description Location Source
#

Additional Information About People & Organizations

People

Name Specialty Relation Identification Numbers Phone Address/ E-mail
:


,

Organizations

Name Specialty Relation Identification Numbers Phone Address/ E-mail
:


,

Information Systems

Name Type Version Identification Numbers Phone Address/ E-mail
:


,

January February March April May June July August September October November December Sunday Monday Tuesday Wednesday Thursday Friday Saturday Z ' Invalid token in format string: AD BC PM AM UTC UTC 7
() () MMM dd, yyyy : - (for )
(for )

The stylesheet used to generate this view of the CCR was provided by the American Academy of Family Physicians and the CCR Acceleration Task Force
Powered by the ASTM E2369-05 Specification for the Continuity of Care Record (CCR)