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Established Provider Order for RPM/CCM
ONLY USE IF: TeleMate Health has established access to your EMR
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Provider Name
*
Provider's Practice Name
Provider Phone Number
Please enter a valid phone number.
Provider Email
example@example.com
Patient to begin Chronic Care Management?
*
Yes
No
Patient to begin Remote Patient Monitoring with the following peripherals.
Vital Sign Goals
Please slide to indicate changes to parameters. Standard parameters are preset. Readings above or below set parameters will alert nurse. Please slide to indicate changes to parameters. Standard parameters are preset. Readings above or below set parameters will alert nurse. Please see preset parameters and adjust as needed. If a pt is having variation in BP and with some high readings, ask the pt to check BP before medication administration and again in the afternoon at least 2-3hrs after medication has been taken. Then add all the SPB values together, need at least 20 readings and take the average. This will be used to determine if the BP is controlled or not. Goal for < 60 would be 130, goal for > 60 would be 150 with no history of CVA, < 140 with history of CVA. This may help to determine if you need to contact PCP or not.
Blood Pressure - Systolic (mmHg)
Blood Pressure Diastolic (mmHg)
Heart Rate
O2 Stats
Blood Glucose
Weight
Weight gain of 2 lbs or more in 2 consecutive days, or 5 lbs in a week
Notes:
Today's Date:
*
-
Month
-
Day
Year
Signature
*
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