Urinary Tract Infection
Plan (4 pronged-plan for each problem on the problem list)
Diagnostics: Urinary tract infection
Treatment: (please use Guidelines reference)
Education:
Follow Up:
List plan under each Diagnosis.
Example
1: Hypertension (I10)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed
2: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education
3: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when sick
E. Return to clinic in 3-4 months to reassess