COGNITIVE IMPAIRMENT
Clinical Action Plan (Flow Sheet)
website: www.BCGuidelines.ca
NAME OF PATIENT
SEX
M
DIAGNOSIS
CARE OBJECTIVES
Diabetes
HTN
CAD
Atrial fib
Asthma
COPD
Renal disease
Depression
Baseline Investigations (pwhen done; normal or add values prn)
FBG
ECG
TSH
Other
GFR
CBC
B12
Ca
Other:
HbA1c
EDUCATION
DATE OF DIAGNOSIS
OCCUPATION
SELF MANAGEMENT (discuss with patient & caregiver)
RISK FACTORS AND COMORBID CONDITIONS
Obesity
Smoker
Alcohol
DATE OF BIRTH
F
SMMSE
Score
Date:
MoCA
Score
Date:
Define management goals (risk factor reduction; treat
co-morbid conditions; case management)
Functional status (baseline & review at each visit)
ADLs:
IADLs:
•Bathing/toileting
•Housework
•Dressing
•Meal prep
•Mobility
•Shopping
•Transportation
•Finances
•Managing meds
Supports (home care, family, case manager, living situation)
Caregiver issues (behaviour/sleep/mood)
Advance care planning/DNR discussion
VISITS
DATE
BP
HR
WEIGHT
Lbs
Kg
SMMSE
SCORE
(Review care objectives, management goals, functional status, symptoms, medications/polypharmacy)
BASELINE
REVIEW CLINICAL ACTION PLAN
VACCINATIONS
Annual Flu:
Date:
Date:
Pneumovax:
Date:
DIAGNOSTIC CODE (Dementia): 290
For information on billing complex care incentive fees, please visit: www.GPSCbc.ca.
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Cognitive Impairment – Recognition, Diagnosis and Management in Primary Care:
Cognitive Impairment Clinical Action Plan (Flow Sheet) (2014)